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BOOK    370. 6273. N2  13Y   v.9   c.  1 
NATTIONAL    SOCIETY    FOR    THE    STUDY 
OF    EOUCATION    #    YEARBOOK 


L 

The  Ninth  Yearbook 


NATIONAL   SOCIETY    FOR   THE    STUDY 
OF    EDUCATION 

Part    II 
THE    NURSE    IN   EDUCATION 

BY 

Thomas  Denison  Wood,  A.M.,  M.D. 

Professor  of  Physical   Education,  Teachers  College  and  Columbia  University,  and  Physician  of  the 

Horace  Mann  School 

M.  Adelaide  Nutting 

Professor  of  Nursing  and  Health,  and  of  Household  Administration,  Teachers  College 
New  York  City 

Isabel  M.  Stewart 

Instructor  in  Nursing  and  Health,  Teachers  College,  New  York  City 

» 

Mary  L.  Read,  B.S. 


SUPPLEMENT  TO  THE  YEARBOOK  ON  "HEALTH  AND  EDUCATION"  DISCUSSED   AT 

THE  INDIANAPOLIS]  MEETING  OF  THE  NATIONAL  SOCIETY 

FEBRUARY  28,  1010 


THE  UNIVERSITY  OF  CHICAGO  PRESS 
CHICAGO,  ILLINOIS 


Copyright  1911   By 

S.  Chester  Parker 

SECRETARY    OF    THE    SOCIETY 


Published  February  1911 


Composed  and  Printed  By 

The  University  of  Chicago  Press 

Chicago,  Illinois,  U.S.A. 


OFFICERS  AND  EXECUTIVE   COMMITTEE 


President 

Clarence  F.  Carroll 

Superintendent  of  Schools,  Rochester,  N.Y. 

Secretary-  Treasurer 

S.  Chester  Parker 

The  University  of  Chicago 

Executive  Committee 
(The  year  indicates  date  of  expiration  of  term) 

Reuben  Post  Halleck  (191  i) 

Principal  Male  High  School,  Louisville,  Ky. 

W.  S.  Sutton  (1912) 

University  of  Texas,  Austin,  Texas 

Henry  Suzzallo  (1913) 

Columbia  University,  New  York  City 

Charles  McKenny  (19 14) 
State  Normal  School,  Milwaukee,  Wis. 

Board  of  Trustees 

J.  Stanley  Brown  (191 1) 

Superintendent,  Township  High  School,  Joliet,  111. 

Charles  H.  Judd  (191 2) 

The  University  of  Chicago,  Chicago,  111. 

Manfred  J.  Holmes  (1913) 

State  Normal  University,  Normal,  111. 


TABLE  OF  CONTENTS 

PAGE 

Preface    7 


Introduction 9 

Thomas  D.  Wood 

The  Educational  Value  of  the  Nurse  in  the  Public  School      14 
Isabel  M.  Stewart,  with  the  co-operation  of 
M.  Adelaide  Nutting 

Professional  Training  of  Children's  Nurses  .       .       .       .      61 
Mary  L.  Read 

Bibliography 72 


PREFACE 

The  purpose  in  this  second  part  of  the  Ninth  Yearbook  is  to  present 
a  brief  survey  of  the  entrance  into  the  work  of  public  education  of  the 
professionally  trained  nurse;  to  bring  together  some  of  the  important 
results  already  attained  in  this  field;  to  indicate  the  scope  and  possi- 
bilities of  the  work  of  this  educational  nurse;  to  suggest  the  relation- 
ship of  the  nurse  to  the  school  and  community,  and  to  indicate  the 
co-ordination  of  the  nurse's  work  with  that  of  parent,  regular  teacher, 
school  physician,  teacher  of  physical  education,  and  other  special 
teachers  whose  particular  subjects  bring  them  into  relation  with  the 
health  side  of  education.  Valuable  help  and  guidance  have  been  given 
in  the  preparation  of  this  report  by  Professor  Henry  Suzzallo. 


INTRODUCTION 


THOMAS  D.  WOOD 


The  most  important  of  all  the  nation's  resources  is  the  health  of  the 
people. 

The  most  valuable  asset  in  this  capital  of  national  vitality  is  the 
health  of  the  children. 

The  public  school  is  the  most  effective  agency  of  the  nation  for  the 
conservation  of  child  health  and  in  the  long  run  the  school  will  become 
the  most  influential  factor  in  the  conservation  of  national  health  as  a 
whole. 

In  the  past  the  schools,  even  under  most  favorable  circumstances, 
have  been  to  some  degree  at  least  disadvantageous,  and  frequently 
directly  dangerous  to  the  health  of  children. 

Some  of  the  factors  inseparable  from  present  school  conditions, 
notably  the  confinement  of  children  in  the  schoolroom;  and  the  segre- 
gation of  pupils,  with  consequent  communication  and  distribution  of 
unrecognized  infection,  present  health  difficulties  whose  solution  will 
tax  all  the  resources  which  knowledge  and  money  may  render  available. 

The  problems  which  have  arisen  out  of  the  great  health  movement 
of  the  present  day  are  many  and  varied.  Many  of  the  most  important 
of  these  are  related  directly  and  indirectly  to  the  work  of  public  educa- 
tion.    Some  of  these  problems  formulate  themselves  as  follows: 

a)  What  may  the  schools  do  to  insure  the  best  possible  physical 
state  of  the  pupil  in  order  that  he  may  be  in  the  most  favorable  condi- 
tion for  the  educational  process  ? 

b)  How  may  all  the  school  conditions  in  the  environment,  the  imple- 
ments and  processes  of  education,  be  made  salutary  and  healthful  in 
their  effects  upon  the  pupil  ? 

c)  What  materials  and  methods  shall  be  utilized  to  inculcate  in  the 
child  practical  motives  and  habits  of  healthful  living,  and  to  provide 
instruction  adequate  for  the  present  and  future  needs  of  the  pupil  in 
relation  to  conduct  affecting  the  health  of  the  individual,  the  home, 
the  community,  and  the  nation  ? 

As  in  the  history  of  public  hygiene,  so  in  the  development  of  school 

9 


io  THE  NINTH  YEARBOOK 

hygiene,  the  first  step  was  to  prevent  and  control  the  spread  of  com- 
municable disease.  To  assist  teacher  and  principal  by  providing  pro- 
fessional skill  for  the  problem ;  to  co-ordinate  the  work  of  school  hygiene 
and  public  health,  provision  has  been  made  variously  and  in  different 
places  for  the  school  physician  or  medical  inspector. 

This  movement  of  medical  inspection  of  schools  has  spread  in  desul- 
tory fashion  through  many  of  the  larger  and  a  few  of  the  smaller  cities 
throughout  the  country,  without  uniformity,  but  in  a  way  to  typify  a 
method  of  organization  suitable  to  a  serious  situation.  However,  between 
the  essential  limitations  of  the  knowledge  of  teacher  and  principal  on  the 
one  hand,  and  of  the  time  of  the  school  physician  on  the  other,  a  striking 
and  significant  hiatus  has  arisen,  so  far  as  the  vital  needs  of  the  child 
are  concerned.  To  bridge  this  gap  which  the  recent  discoveries  in  medical 
science  have  made  more  striking  and  apparent  within  the  last  few  years, 
the  school  nurse  has  come  into  being. 

The  introduction  of  the  graduate  nurse  into  public  education  has 
been  rapid  and  dramatic.  No  innovation  in  the  schools  has  ever  met, 
probably,  with  such  instant  and  spontaneous  support  and  approbation. 
Little  time  will  be  required  to  convince  most  school  authorities  of  the 
wisdom  of  expenditure  involved  in  the  cost  of  the  school  nurse.  Not 
only  has  the  nurse  more  than  fulfilled  expectations  regarding  the  pro- 
fessional services  which  she  was  specifically  appointed  to  render,  but  she 
has  rapidly  developed  forms  of  hygienic  service,  social  and  educational, 
to  pupil,  home,  school,  and  community,  which  have  naturally  grown  out 
of  the  wonderful  opportunities  inherent  in  her  work.  Moreover,  her 
achievements  almost  from  the  beginning  have  demonstrated  the  extra- 
ordinary value  and  significance,  not  only  of  the  direct  but  the  indirect 
and  incidental  features  of  this  new  field  of  service. 

Prominent   among   the   results   already   accomplished   by   capable 
nurses  in  this  field  are  the  following: 
a)  Detecting  early  signs  of  communicable  disease  among  school  children, 

many  of  which  would  otherwise  be  overlooked  altogether  or  until 

the  disease,  if  severe,  would  have  become  more  pronounced  with 

much  more  extensive  infection  of  fellow-pupils. 

This  early  detection  of  disease  symptoms  results  variously  in : 

i.  Marked  reduction  in  the  number  of  cases  of  infectious  disease 
due  to  segregation,  with  consequent  actual  saving  of  child  life 
and  reduction  of  school  child  mortality. 


INTRODUCTION  1 1 

2.  Early  treatment  of  disease,  with  frequent  lessening  of  danger 
and  severity  of  the  disease. 

b)  Treatment  in  school  of  minor  accidents  and  ailments  and  of  mild 
cases  of  local  infection  under  medical  direction,  with  consequent 
reduction  to  a  minimum  of  educational  loss  due  to  exclusion  from 
school  for  various  forms  of  injury  and  disease. 

c)  Instruction  of  mother  in  the  care  of  the  child,  in  the  health  of  the 
household,  and  in  manifold  aspects  of  the  life  of  the  family,  with 
consequent  benefit  to  the  community. 

d)  Supervision  of  sanitary  conditions  of  the  school. 

e)  Health  guidance  and  instruction  given  to  individuals  and  groups, 
according  to  local  conditions,  and  the  opportunities  afforded. 

While  certain  aspects  of  the  work  of  the  nurse  in  the  school  will  be 
made  uniform  by  formal  regulation  and  accumulating  tradition,  still 
many  of  the  most  valuable  features  here  must  depend  upon  local  need 
and  circumstances;  upon  personality,  skill,  and  tact  of  the  individual 
nurse. 

On  the  side  of  her  work  which  involves  prevention,  detection,  and 
care  of  disease,  the  nurse  becomes  the  skilled  helper  of  the  school 
doctor,  public  health  officer,  and  family  physician. 

In  aspects  of  school  administration  she  must  act  as  assistant  of 
school  superintendent  and  principal.  Where  her  work  touches  that  of 
regular  and  special  teachers  in  the  school,  intelligent  and  sympathetic 
co-operation  is  required. 

In  her  contact  with  the  home,  wisdom,  tact,  and  fine  judgment 
are  needed  in  order  that  information,  suggestion,  and  inspiration  may 
be  furnished  in  a  way  to  incite  to  better  standards  of  living  and  a  finer 
conduct  of  individual,  home,  and  community.  So  far  as  the  welfare 
of  the  child  is  concerned,  such  an  adjustment  and  co-ordination  of 
forces  and  persons  are  required  as  to  permit  no  needless  and  wasteful 
overlapping  of  factors  in  the  mosaic  of  influences  intended  for  the  pro- 
tection and  training  of  the  child,  and  at  the  same  time  to  leave  no  gap 
in  this  composite  of  forces  which  will  result  in  neglect  or  injury. 

The  school  nurse  comes  into  the  field  of  education  to  fill  an  important 
gap  in  the  protection  of  the  child's  health  and  to  supplement  in  various 
ways  the  sum  of  the  influences  intended  for  the  improvement  of  indi- 
vidual, home,  school,  and  community  life.     It  is  very  evident  that  if 


12  THE  NINTH  YEARBOOK 

the  school  or  district  nurse  is  to  be  sufficient  not  only  for  strictly  pro- 
fessional duties,  but  for  the  broader  and  indirect  opportunities  of  her 
calling,  this  field  of  effort  must  command  the  finest  type  of  womanhood 
in  respect  to  understanding,  sympathy,  sound  judgment,  and  practical 
tact  in  dealing  with  the  manifold  problems  which  she  will  meet.  While 
some  of  the  best  elements  of  this  nurse's  ability  can  arise  only 
from  actual  experience,  yet  a  new,  comprehensive,  and  varied  type  of 
training  must  be  developed  to  supplement  the  technical  education  of 
the  nurse  and  to  prepare  her  as  well  as  may  be  possible  for  this  new 
vocation. 

Closely  related  in  certain  respects  to  this  profession  of  the  edu- 
cational nurse  is  the  field  of  service  and  responsibility  which  must 
be  developed  in  the  near  future  for  the  woman  who  is  fitted  to  take 
professional  care  of  the  infant  and  the  "runabout"  child  below  the 
kindergarten  age.  While  most  of  the  practical  care  of  the  baby  relates 
to  his  physical  life  and  needs,  yet  the  mental  and  moral  education  of 
the  child  begins  from  the  time  of  birth.  Vital  foundations  of  intellect, 
personality,  and  character  are  laid  in  the  cradle  and  in  the  nursery. 
The  simplest  reactions  of  the  central  nervous  system  in  infancy,  and 
many  of  the  early  habits  involved  in  the  physical  beginnings  of  life,  form 
the  germs  of  education  and  are  of  great  potency  in  the  determination 
of  the  final  characteristics  of  the  individual. 

The  most  important  part  of  education  in  some  respects  occurs  before 
the  child  is  old  enough  to  enter  the  kindergarten  or  the  school.  The 
early  care  of  the  baby  should  be  intrusted  to  a  woman  who  not  only 
is  qualified  to  give  the  physical  care  required,  but  who  is  able  to  watch 
and  guard  the  child  with  appreciation  of  the  significance  of  all  the  factors 
at  this  first  stage  of  development  in  relation  to  his  future  well-being. 

The  nurse-maid  of  the  present  is  generally  inadequate  and  incom- 
petent. Her  position  in  the  family  and  in  society  is  entirely  beneath 
the  right  and  dignity  of  a  woman  qualified  to  do  this  important  work. 
The  demand  for  well-educated  women  in  this  field  will  come  naturally 
from  the  homes  of  the  wealthy  and  well-to-do,  where  the  conscientious, 
devoted  care  of  the  young  is  so  often  lacking. 

Here,  then,  is  the  prospect  of  another  new  skilled  profession  for 
women  which  will  call  for  as  high  a  type  as  the  fields  of  teaching  and 
nursing.  Provision  must  be  made  in  the  near  future  for  the  compre- 
hensive training  of  children's  nurses  who  shall  be  qualified  to  care  for 


INTRODUCTION  13 

the  physical,  intellectual,  and  moral  beginnings  of  child  development. 
The  development  of  this  field  must,  in  time,  influence  favorably  the 
standards  of  mother  care  in  all  types  of  society.  These  phases  of 
nursing  affecting  the  infant,  runabout,  and  school  child  will  help  fill 
some  of  the  glaring  gaps  of  the  present  in  the  complete  human  nurture 
of  the  young. 


THE   EDUCATIONAL  VALUE   OF  THE  NURSE   IN  THE 
PUBLIC  SCHOOL 


ISABEL  M.  STEWART 

with  the  co-operation  of 
M.  ADELAIDE  NUTTING 


It  is  a  significant  sign  of  the  times  that  so  much  attention  is  being 
paid  to  the  health  of  school  children.  Medical  societies,  sanitarians,  and 
public-health  officials  are  concerning  themselves  seriously  with  the 
physical  defects  of  children  and  with  the  spread  of  contagious  diseases 
through  the  schools.  Economists  are  accumulating  a  great  body  of 
statistics  to  show  the  enormous  wastage  of  human  life  through  the 
diseases  of  infancy  and  childhood,  and  the  economic  loss  to  the  nation 
from  this  mortality,  as  well  as  from  the  serious  weakening  in  efficiency 
and  earning  power,  due  to  preventable  and  remediable  defects.  Philan- 
thropic and  charitable  societies  are  concerning  themselves  chiefly  with  the 
social  and  moral  aspects  of  the  problem.  The  economic  and  industrial 
situation  is  complicated  by  the  terrible  prevalence  of  ignorance,  due 
to  the  lack  of  proper  teaching  somewhere.  The  schools  cannot  evade 
some  of  the  responsibility.  Educationalists  have  always  maintained 
the  importance  of  the  healthy  body  as  a  basis  for  the  educational  pro- 
cess, but  they  are  just  beginning  to  realize  how  large  a  factor  the  school 
itself  is,  in  manufacturing  defects,  and  in  propagating  disease  in  the 
community. 

THE   PROBLEM 

It  seems  so  obvious  as  to  require  no  argument,  that  children  in  ill 
health  should  have  attention,  that  the  health  of  well  children  should  be 
protected  and  conserved,  that  defects  which  interfere  with  mental 
development  should  be  treated  and,  so  far  as  possible,  cured,  that  the 
school  environment  and  educational  method  should  at  least  not  con- 
tribute to  ill  health.  It  is  being  stated  freely  that  the  evils  of  child 
labor  are  not  all  the  results  of  commercial  exploitation,  that  the  crowded 
classrooms  in  some  of  our  cities  are  close  competitors  with  the  cotton 
mills  of  the  South,  and  that  "our  buildings,  our  curricula,  our  home 
study,  are  manufacturing  more  defects  than  the  physician  and  nurse 

14 


EDUCATIONAL  VALUE  OF  THE  NURSE  15 

and  dispensary  can  correct."1  The  Committee  on  the  Physical  Welfare 
of  School  Children  in  New  York2  found  that  66  per  cent  needed  medical 
or  surgical  attention  or  better  nourishment;  40  per  cent  needed  dental 
care;  3S  per  cent  had  enlarged  glands  of  the  neck;  31  per  cent  had 
defective  hearing;  iS  per  cent  had  enlarged  tonsils.  These  defects 
are  not  confined  to  the  very  poor,  nor  to  the  children  of  immigrant 
parents.  Such  statistics  are  before  the  public  and  are  well  known  to 
educationalists.  They  have  been  fully  presented  to  this  Society  in  the 
first  part  of  the  Ninth  Yearbook.  In  most  enlightened  communities 
boards  of  education  and  boards  of  health  have  combined  to  investi- 
gate conditions  and  to  demonstrate  the  need  of  better  sanitation,  better 
teaching  of  hygiene,  and  medical  treatment  for  these  seriously  handi- 
capped children. 

The  medical  inspector  himself  cannot  do  much  to  bring  about  better 
conditions.  He  must  not  even  treat  the  children  except  for  minor  ail- 
ments. All  he  can  do  is  to  report  what  he  finds,  to  exclude  those  children 
who  are  a  menace  to  others,  and  to  agitate  for  something  to  be  done. 
It  seems  impossible  any  longer  to  fix  the  responsibility  for  the  child's 
health  exclusively  on  the  parents.  Because  of  ignorance,  or  poverty, 
or  inefficiency  in  the  home;  because  of  the  large  proportion  of  the 
foreign  element  in  our  population,  the  employment  of  mothers  in 
industry,  the  increasing  congestion  in  cities,  and  the  consequent  over- 
crowding of  classrooms,  the  school  is  compelled  to  take  over  many  of 
the  functions  which  formerly  devolved  on  the  home.  There  is  thus  an 
increasing  accumulation  of  school  functions  relating  to  health.  These 
may  be  cited  briefly: 

a)  Sanitary  inspection  of  school  buildings,  systems  of  ventilation,  etc., 
with  special  attention  to  the  daily  cleaning  and  the  disinfection  of 
schoolrooms  and  lavatories. 

b)  Medical  inspection  for  detection  of  contagious  diseases  and  physical 
defects. 

c)  Personal  health  examination. 

d)  Hygiene  of  instruction. 

e)  Emergency  service  and  treatment  of  minor  chronic  complaints. 

1  Ninth  Yearbook,  52.  ^ 

2  Professor  Irving  Fisher,  Report  on  National  Vitality,  74. 


16  THE  NINTH  YEARBOOK 

f)  Instruction  of  children  in  personal,  home,  and  community  hygiene 
and  sanitation,  and  the  practical  application  of  the  laws  of  health. 

g)  Instruction  of,  and  co-operation  with,  parents. 
h)   Physical  education. 

METHODS   OF   DEALING   WITH  THE   PROBLEM 

It  is  perfectly  evident  that  the  existing  organization  is  powerless  to 
handle  all  these  varied  phases  of  the  health  problem.  As  a  matter  of 
fact  the  teaching  staff  is  already  so  overloaded  with  duties  that  it  could 
not  seriously  undertake  more.  But  even  where  some  attempt  is  being 
made  to  cover  the  field,  it  fails  in  effectiveness  because  of  the  lack  of 
co-ordination  of  the  various  forces  engaged.  For  instance,  in  the 
question  of  personal  hygiene,  four  or  five  different  instructors  are 
already  teaching  the  subject  in  different  ways  and  from  various  stand- 
points— the  regular  teacher,  the  domestic  science  teacher,  the  super- 
visor of  physical  education,  the  special  teacher  of  nature-study  or 
biology,  the  school  doctor,  and  if  there  is  one,  the  school  nurse.  Yet, 
with  some  excellent  exceptions,  the  subject  is  notoriously  slighted,  and 
there  is  little  practical  application  of  the  principles  of  hygiene  to  every- 
day living. 

Dr.  William  H.  Allen  says: 

The  teachers  themselves,  especially  in  the  higher  grades,  are  the  first  to 
acknowledge  that  they  have  no  adequate  training  for  the  work,  and  are  not 
themselves  very  correctly  informed  on  questions  relating  to  even  sanitation 
and  personal  hygiene,  and  less  on  such  subjects  as  the  nature  and  control  of 
infectious  diseases,  the  prevention  of  tuberculosis,  etc.1 
and  again: 

Superintendent  Maxwell  of  New  York  City,  and  other  educational  lead- 
ers, urge  teachers  to  do  their  utmost  to  learn  the  physical  conditions  and 
home  environment  of  the  individual  child  and  to  fit  school  treatment  to  the 
individual  possibilities  and  handicaps.  But  experience  proves  conclusively 
that,  try  as  they  will,  teachers  and  principals  have  neither  the  special  knowl- 
edge nor  the  time  to  acquire  the  special  knowledge  to  use  the  facts  disclosed 
by  the  physical  examination  of  school  children. 

Professor  Irving  Fisher2  points  out  very  clearly  that  in  respect  to 
school  hygiene,  it  is  not  so  much  lack  of  knowledge,  as  lack  of  applica- 

1  Civics  and  Health,  286. 

2  Report  of  National  Vitality,  chap,  ix,  "Conservation  through  Personal  Hygiene." 


EDUCATIONAL  VALUE  OF  THE  NURSE  17 

tion  of  knowledge,  which  is  at  fault.  To  be  effective,  this  application 
must  be  made  largely  in  the  home  where  the  trouble  arises,  and  here  is 
where  the  whole  difficulty  lies.  The  teacher  or  the  specialist  cannot 
be  asked  to  take  on  the  function  of  health  visitor  and  sanitary  instructor 
in  the  home. 

There  is  then  a  very  evident  need  for  some  organized  expert  agency 
within  the  school  system,  to  co-ordinate  these  various  offices  connected 
with  the  health  of  the  school  child.  This  is  not  a  new  idea  in  education. 
Boards  of  education  have  already  appointed  trained  specialists  for  the 
teaching  of  art,  manual  training,  music,  physical  education,  domestic 
science,  etc.  Why  should  we  not  have  supervisors  of  health  in  the 
schools  ? 

The  difficulty  is  in  securing  the  right  type  of  specialist  for  such  a 
varied  line  of  activities.  Dr.  Snedden,  in  advocating  such  a  system, 
says: 

It  should  be  noted  that  at  present  there  are  hardly  anywhere  men  and 
women  who  can  be  put  in  charge  of  this  work  of  educational  hygiene,  for 
men  skilled  in  medical  science  alone  cannot  do  it,  nor  can  men  who  are  only 
teachers.  It  requires  a  combination  of  the  results  of  both  kinds  of  training — 
in  fact,  a  new  field  of  applied  science.  But  if  the  demand  is  once  created, 
gradually  a  supply  of  trained  workers  will  be  available,  for  the  field  offered  is 
certainly  attractive  to  all  who  incline  toward  sanitation  and  preventative 
medical  practice.1 

In  the  meantime  we  must  look  to  those  who  are  already  in  the  field 
and  try  to  determine  which  of  the  many  types  of  specialist  might  best 
be  intrusted  with  the  present  situation.  We  have  already  a  very  few 
specially  trained  physicians  who  combine  a  thorough  knowledge  of 
disease,  its  prevention  and  treatment,  with  a  training  in  physical  edu- 
cation and  a  knowledge  of  educational  psychology  and  sociology.  Such 
a  person  would  undoubtedly  be  the  one  to  direct  and  co-ordinate  all  the 
functions  outlined. 

For  that  part  of  the  work  which  concerns  itself  specially  with  the 
prevention  and  treatment  of  diseases,  it  would  seem  that  a  very  satis- 
factory basis  would  be  found  in  the  co-operation  of  specially  trained 
physicians  and  nurses  in  a  well-organized,  adequately  supported  sys- 
tem of  medical  inspection  in  the  schools.  The  history  of  the  movement 
most  significantly  demonstrates  the  effectiveness  of  such  a  combination 

1  Report  of  International  Congress  on  Tuberculosis,  Vol.  III. 


18  THE  NINTH  YEARBOOK 

wherever  it  has  been  tried,  but  its  full  possibilites  have  not  really  been 
tested.  While  acknowledging  the  control  of  the  medical  officers  in 
everything  that  pertains  to  diagnosis  and  individual  treatment,  I  wish 
to  show  that  the  nurse  has  a  field  here  which  is  peculiarly  her  own;  that 
she  accomplishes  through  her  close  personal  contact  with  the  child  and 
the  home  something  which  has  not  been  accomplished  in  other  ways; 
that  she  is  a  social,  an  educational,  and  an  economic  factor  of  great  sig- 
nificance in  this  movement;  and  that  an  extension  of  her  work  would 
greatly  increase  the  efficiency  of  the  public  school. 

HISTORY  AND  DEVELOPMENT   OF   SCHOOL   NURSING 

Germany. — The  development  of  the  system  of  medical  inspection 
in  Germany  has  been  fully  discussed  in  Part  I  of  the  Ninth  Yearbook. 
It  will  be  noted  that  the  duties  of  the  school  physician  include  such 
details  as  the  inspection  of  buildings  and  playgrounds,  lighting,  heat- 
ing, ventilation,  choice  of  desks,  and  the  hygiene  of  instruction,  as  well 
as  the  thorough  and  regular  physical  examination  of  the  school  children 
under  his  care. 

The  results  of  these  examinations  are  reported  quite  fully  to  the 
parents,  and  if  necessary  the  pupil  is  excluded  until  treatment  is  given. 
German  parents  evidently  take  their  duties  a  little  more  seriously  than 
either  English  or  American  parents,  for  there  seems  to  be  no  serious 
trouble  in  securing  their  interest  and  co-operation  in  the  treatment  of 
defects  or  disabilities.  In  some  cities  a  fine  is  charged  for  every  day 
of  non-attendance,  where  this  is  due  to  carelessness  or  negligence  on 
the  part  of  the  parents.  No  attempt  is  made  to  treat  the  children  in 
the  school,  or  to  follow  them  to  their  homes.  Indeed  the  family  physi- 
cians strenuously  oppose  any  suggestion  of  treatment  on  the  part  of  the 
school  physicians.  Their  work  with  the  children  is  confined  to  the 
investigation,  diagnosis,  and  reporting  of  abnormal  conditions  and  the 
exclusion  of  contagious  disease.  The  poorer  children  are  referred  to 
dispensaries  and  clinics  for  treatment.  As  a  rule  the  school  physician 
has  from  2,000  to  3,000  children  under  his  care,  and  gives  his  services 
for  a  part  of  the  day  only,  at  a  salary  of  from  $125  to  $200  per  year. 
The  teachers  assist  in  the  routine  measurements  and  are  taught  to 
detect  the  common  diseases  of  childhood.  So  far  as  can  be  gathered 
from  reports,  nurses  have  never  been  employed  in  the  German  system, 
nor  in  the  continental  schools  generally.     Yet  it  is  stated  "that  out  of 


EDUCATIONAL  VALUE  OF  THE  NURSE  19 

35,000  children  examined  for  admission  to  school  in  Berlin  in  1905,  no 
less  than  3,000  were  rejected  and  sent  back  home,  and  7,600  were  put 
under  special  medical  treatment."1  It  would  seem  that  there  is  room 
for  some  home  instruction  even  in  Germany.  Probably  one  reason 
why  nurses  have  such  limited  opportunities  there  is  because  the  nursing 
schools  are  largely  under  the  domination  of  the  religious  authorities 
and  have  had  less  opportunity  for  development. 

Great  Britain. — In  the  International  Congress  of  Hygiene  and  Demog- 
raphy in  1 89 1,  Dr.  Malcolm  Morris  advocated  the  employment  of  a 
staff  of  specially  educated  nurses  to  visit  the  public  elementary  schools 
and  inspect  the  children.  This  seems  to  be  the  first  public  suggestion 
of  such  a  plan. 

In  England  the  work  of  school  nursing  preceded  medical  inspection 
in  the  present  accepted  sense.  There  was  indeed  one  permanent  medi- 
cal officer  in  the  city  of  London  whose  duty  it  was  "to  sit  up  in  the 
central  office  and  collect  statistics."2  In  1894  the  managers  of  a  school 
in  a  very  poor  district  of  London  asked  a  district  nurse  to  visit  the 
school  and  do  what  she  could  to  relieve  the  small  ills  of  the  children. 
Her  work  was  found  to  be  very  beneficial,  and  was  brought  to  the 
notice  of  one  of  the  members  of  the  London  School  Board,  Miss  Honnor 
Morten,  herself  a  nurse  and  a  prominent  social  worker  and  therefore 
better  able  perhaps  to  appreciate  what  was  being  done.  No  organ- 
ized movement  was  made  till  1898  when  a  voluntary  "  School  Nurses' 
Society"  was  founded  with  the  object  of  supplying  visiting  nursing  to 
elementary  schools  in  poor  districts.  Three  nurses  were  appointed, 
each  with  four  schools  under  her  care.  They  treated  the  children  sent 
to  them  by  the  teachers,  followed  the  worst  cases  to  their  homes,  secured 
medical  attendance  for  those  who  required  it,  and  everywhere  taught 
and  demonstrated  the  principles  of  cleanliness  and  simple  hygiene.  In 
one  of  its  reports  the  School  Nurses'  Society  briefly  describes  its  purpose: 

It  must  be  remembered  that  the  sore  heel  soon  becomes  poisoned  if  left 
to  London  dirt,  and  that  the  inflamed  eyes  often  lose  the  power  of  seeing, 
simply  through  neglect.  There  is  no  more  sure  way  of  securing  the  health 
of  the  people  than  to  arrest  small  ills  at  the  beginning.    A  nurse  can  see  at 

1  Dr.  Frederick  Rose,  International  Congress  of  Nurses  (London);  reported  in 
British  Journal  of  Nursing  (November  20,  1909). 

2  Honnor  Morten,  "The  London  Public  School  Nurse,"  American  Journal  of 
Nursing  (January,  1901). 


20  THE  NINTH  YEARBOOK 

a  glance  whether  a  child  should  be  sent  to  a  doctor,  she  can  impress  cleanli- 
ness, she  can  follow  up  bad  cases  to  their  homes,  she  can  recognize  the  early 
symptoms  of  fevers  and  do  much  to  stop  the  spread  of  infectious  diseases 
that  so  often  devastate  our  schools.1 

It  was  found  that  cases  of  bad  eyes  and  dirty  heads  were  practically 
stamped  out  of  school  by  six  months  of  regular  visiting.  The  funds  to 
pay  the  nurses  and  provide  dressings  were  raised  by  voluntary  sub- 
scription, and  as  soon  as  finances  permitted,  extra  nurses  were  added 
to  the  staff.  Efforts  were  made  to  interest  the  authorities  and  secure 
their  co-operation.  Through  Miss  Morten  and  Lord  Breay,  members 
both  of  the  School  Board  and  of  the  School  Nurses'  Society,  permission 
had  been  granted  in  the  beginning,  on  the  express  stipulation  that  no 
expenditure  should  be  entailed  in  carrying  out  the  experiment.  Later 
the  board  graciously  consented  to  provide  a  basin  and  kettle  for  the 
use  of  the  nurse  in  each  school,  with  the  proviso  that  the  outlay  should 
not  exceed  three  shillings  for  the  two  articles.2 

Everywhere  the  same  story  was  told  of  the  schools — that  they  were 
centers  of  contagion,  especially  for  such  evils  as  pediculi  and  ringworm.  A 
specially  virulent  form  of  ringworm  having  broken  out  in  the  London  schools 
in  1900,  the  School  Board  cautiously  appointed  one  nurse,  at  a  salary  of 
seventy  pounds  a  year,  to  inspect  the  children's  heads.  There  were  three 
and  one-half  million  children  attending  these  schools.3 

On  the  appointment  of  an  active  and  intelligent  physician  (Dr. 
Kerr)  as  medical  officer  to  the  London  School  Board,  the  whole  terrible 
condition  of  the  children  in  the  schools  came  before  the  public.  In 
1904  the  work  of  the  School  Board  was  taken  over  by  the  London  County 
Council  and  put  under  a  progressive  management.  The  London 
School  Nurses'  Society,  having  demonstrated  the  value  of  the  nurses' 
services  in  the  school  for  five  years,  now  applied  to  the  council  to  have 
the  system  taken  over  and  supported  by  municipal  funds.  This  was 
done  and  the  staff  of  nurses  was  increased  to  twelve  and  later  to  fifty. 
But  the  character  of  the  work,  as  determined  by  the  County  Council, 
was  altered,  so  that  the  nurses  were  obliged  to  restrict  their  duties 
merely  to  reporting,  excluding,  and  giving  cards  of  instruction.    Thus 

1  Honnor  Morten,  "School  Nurses  in  England,"  Charities  and  the  Commons 
(April  7,  1906). 

2  School  Board  of  London  Gazette  (February  27,  1900). 

3  Honnor  Morten.     See  p.  19,  n.  2,  and  n.  1,  above. 


EDUCATIONAL  VALUE  OF  THE  NURSE  21 

the  nurse  is  simply  an  inspector,  and  her  work  is  robbed  of  its  prime 
significance  by  the  elimination  of  the  actual  nursing  treatment,  and  the 
home  visiting  with  its  resulting  educational  benefits. 

The  example  of  London  was  speedily  followed  by  Liverpool,  Birm- 
ingham, and  other  big  towns,  and  although  some  of  them  have  secured 
municipal  aid  for  their  nursing  staff,  in  many  cases  they  are  still  paid 
by  voluntary  agencies.  The  effectiveness  of  medical  inspection  is 
proven  to  be  dependent  on  the  thoroughness  and  regularity  of  the 
doctor's  visits,  and  the  character  of  his  work,  but  more  than  all  on  the 
co-operation  of  an  efficient  nursing  staff. 

Dr.  Hayward,  of  Wimbledon,  England,  in  his  very  interesting 
address  given  before  the  Jubilee  Congress  of  District  Nursing  held  in 
Liverpool,  May,  1909,  gives  a  vivid  picture  of  the  helplessness  of  a  doctor 
working  alone  in  a  school.     He  says: 

As  a  doctor  I  felt  quite  stranded  in  the  strange  atmosphere  of  an  elemen- 
tary school,  coming  into  contact,  not  so  much  with  actual  illness,  as  with  the 
primary  conditions  which  produce  and  foster  it.  Dirt,  neglect,  improper 
feeding,  malnutrition,  insufficient  clothing,  suppurating  ears,  defective  sight, 
verminous  conditions,  the  impossibility  of  getting  adequate  information  from 
the  children  or  a  knowledge  of  their  home  conditions;  and  nobody  to  whom 
one  could  give  directions  or  who  could  help  in  examining  the  children.  The 
only  means  of  approaching  the  parents  was  to  send  an  official  notice  that 
such  or  such  a  condition  required  treatment.  My  duties  began  and  ended 
with  endless  notifications,  and  there  it  all  stopped,  as  very  little  notice  was 
taken  of  them.1 

United  States. — It  was  from  the  work  in  London  that  the  suggestion 
came  for  a  nursing  staff  in  the  schools  of  New  York.  In  1897  one 
hundred  and  fifty  medical  inspectors  had  been  appointed  by  the  Board 
of  Health  to  visit  the  schools  each  day,  and  inspect  all  children  sent  to 
them  by  the  teachers.  The  great  object  was  to  safeguard  the  health 
in  the  schools  by  excluding  those  affected  with  contagious  diseases. 
The  first  year  108,628  examinations  were  made  and  6,829  children 
were  excluded  on  account  of  some  defect  or  contagion.  In  1902  the 
exclusions  had  risen  to  17,986.  At  the  beginning  of  the  school  term 
it  was  said  that  from  15  to  20  children  were  excluded  daily  and  some- 
times as  many  as  300  out  of  a  single  school  were  out  at  one  time.  There 
was  a  protest  from  teachers  and  parents.     Visitors  from  the  settlements 

1  Quoted  in  Visiting  Nurses'  Quarterly  (Cleveland,  April,  1910). 


22  THE  NINTH  YEARBOOK 

found  the  excluded  children  playing  on  the  streets  with  other  children. 
The  cards  which  had  been  given  them  were  lost  or  thrown  away;  or 
the  parents,  failing  to  understand  the  meaning  of  the  scientific  names 
or  the  directions  on  the  card,  and  unable  to  appreciate  the  purpose  of 
the  whole  thing,  simply  did  nothing.  Miss  Lillian  Wald,  head  worker 
of  the  Henry  Street  Nurses'  Settlement,  who  had  followed  the  work 
of  the  school  nurses  in  England,  drew  the  attention  of  the  Board  of 
Health  to  this  very  serious  condition  of  affairs  and  offered  to  place  one 
of  her  staff  of  visiting  nurses  in  the  schools  for  an  experiment  of  one 
month.  The  work  of  Miss  Lina  L.  Rogers  was  a  convincing  demon- 
stration of  the  value  of  the  trained  nurse  in  the  public  school.1  Where- 
ever  it  was  possible  she  treated  the  child  in  the  school  and  thus  saved 
many  unnecessary  exclusions.  The  work  was  approved  by  Dr.  Lederle, 
the  commissioner  of  health,  and  by  Mr.  Burlingham  of  the  Department 
of  Education.  In  1903,  at  the  request  of  the  Board  of  Health,  $30,000 
was  appropriated  to  extend  the  nursing  service  and  put  it  on  a  definite 
basis.  This  provided  a  staff  of  2  7  nurses  at  $900  per  year.  These  nurses 
attended  125  local  and  4  parochial  schools,  with  an  attendance  of  219,- 
239  pupils.  Under  the  new  system  the  number  excluded  for  the  month 
of  September,  1903,  was  1,101,  as  compared  with  10,567  for  the  same 
month  in  1902.  Since  that  time  the  New  York  staff  has  been  increased 
to  141  nurses,  including  supervisors,  all  giving  their  entire  time  to  the 
work. 

Dr.  Cronin  of  New  York  maintains  that  in  a  school  population  of 
650,000,  30  per  cent  of  the  children  were  from  1  to  2  years  behind  their 
proper  class.  Of  these  backward  children  95  per  cent  were  so  prin- 
cipally because  of  defects  of  eye,  ear,  nose,  or  throat,  which  could  easily 
have  been  detected  and  remedied  through  effective  medical  inspection.3 
From  the  work  of  the  school  nurses  he  testified  that  "exclusion  has 
been  reduced  99  per  cent,  thus  saving  the  city  large  sums  of  money  and 
annulling  all  the  obnoxious  features  of  wholesale  exclusion  which,  if 
continued,  would  contribute  to  truancy  and  illiteracy."3 

'Lina  L.  Rogers,  "School  Nursing  in  New  York  City,"  American  Journal  of 
Nursing  (March,  1903);  "Nurses  in  the  Public  Schools  of  New  York  City,"  Charities 
and  the  Commons  (April  7,  1906). 

2  Report  on  National  Vitality,  73. 

3  "Medical  Treatment  at  School,"  Report  of  Second  International  Congress  of 
School  Hygiene  (London). 


EDUCATIONAL  VALUE  OF  THE  NURSE  23 

It  is  stated1  that  when  the  child  takes  ten  years  to  complete  work 
which  should  take  but  eight,  the  cost  of  education  is  increased  25  per 
cent.  It  would  thus  be  possible  to  work  out  on  an  economic  basis  alone 
the  strongest  possible  argument  for  the  employment  of  school  nurses. 

Under  Dr.  Darlington,  the  nursing  service  in  New  York  was  extended 
and  further  organized.  He  is  unqualified  in  his  commendation  of  the 
work  as  a  supplement  to  medical  inspection. 

The  present  method  of  the  medical  inspection  and  examination  of  school 
children  is  noteworthy,  for  the  practice  of  not  only  examining  each  child  for 
physical  abnormalities  but  for  the  method  whereby  the  parents'  attention 
is  called  to  the  presence  of  the  defect,  and  repeated  home  visits  are  made  by 
the  nurses  to  explain  and  urge  the  necessity  of  treatment.  During  the  school 
year  of  1908-9,  323,344  children  were  examined;  242,048  were  found  to  be 
suffering  from  some  non-contagious  physical  defect.  Of  this  number  203,488, 
or  84 .  06  per  cent,  were  placed  under  treatment. 

In  contrast  to  that  I  might  say  that  until  this  last  year,  the  practice  was 
to  send  a  postal  card  to  each  parent  with  return  postage.  We  had  only  two 
per  cent  of  these  cards  returned,  and  we  found  that  six  per  cent  of  the  children 
underwent  treatment  until  this  last  school  year.  Now  84  per  cent  are  put 
under  treatment.  They  are  not  treated  by  the  Health  Department,  but  by 
the  clinics  or  family  physician;  the  attention  of  the  family  is  called  to  the 
trouble. 

This  result  was  made  possible  by  the  effective  work  performed  by  the 
nursing  staff,  and  illustrates  forcibly  the  value  of  individual  contact  in  edu- 
cational work  of  this  nature.2 

Miss  Rogers,  who  was  for  some  years  director  of  school  nursing  in 
New  York,  reports: 

The  principals  tell  us  that  the  condition  in  the  school  is  100  per  cent 
better,  and  that  the  attendance  has  increased  75  per  cent.  What  better 
demonstration  can  be  given  of  the  importance  of  keeping  the  children  in  good 
physical  condition,  to  insure  a  proper  frame  of  mind  to  receive  the  knowledge 
so  freely  imparted  in  the  schools  ? 

Again  from  the  paper  by  J.  A.  Kalb,  I  quote: 

A  study  of  1,400  children  in  New  York  was  begun  in  the  summer  of  1906. 
These  children  had  been  reported  as  needing  medical,  dental,  or  ocular  care, 
or  better  nourishment. 

1  J.  A.  Kalb,  Hygiene  and  Medicine  in  Relation  to  the  School  (Columbia  Univer- 
sity thesis). 

2  Woman's  Municipal  League  Bulletin  (New  York,  January,  1910). 


24  THE  NINTH  YEARBOOK 

The  futility  of  a  physical  examination  without  further  action  to  insure 
medical  treatment  or  hygienic  environment  was  clearly  demonstrated  by 
re-examination  in  the  spring.  In  the  major  number  of  instances  these  chil- 
dren were  found  to  be  worse  than  the  first.  Unless  the  work  is  followed  up, 
no  sufficient  improvement  will  be  made.  The  home  conditions  in  so  many 
cases  are  appalling,  due  to  insufficient  light,  ventilation,  and  poor  food. 

The  experience  of  New  York  in  the  matter  of  exclusions  has  been 
repeated  in  many  other  cities.  According  to  Dr.  Newmayer  of  Phila- 
delphia : 

In  a  school  population  of  157,500,  the  number  of  examinations  made  in 
April,  May,  June,  and  September,  1904,  was  over  700,000.  Those  excluded 
for  contagious  disease  were  7,600.  If  school  nurses  had  been  provided,  7,000 
of  these  could  have  remained  at  school,  or  lost  but  a  short  time. 

Jane  Addams  sums  the  matter  up  in  an  address  on  "The  Visiting 
Nurse  and  the  Public  Schools": 

The  best  of  medical  inspection  succeeds  only  in  sending  the  child  home; 
they  say  that  such  and  such  a  child  would  have  a  bad  effect  on  the  other 
children,  and  therefore  he  is  sent  back  to  the  family  physician  for  treatment. 
In  most  cases  a  family  physiciam  is  not  called  in,  because,  in  the  words  of 
Artemus  Ward,  "  there  ain't  none,"  and  therefore  the  child  is  kept  out  indefi- 
nitely, and  the  public  school,  so  far  as  that  child  is  concerned,  is  doing  nothing, 
and  the  child  continues  to  play  in  the  alley  and  on  the  streets  or  sit  in  the 
doors  of  the  tenement  with  the  rest  of  them. 

This  is  the  whole  idea — that  medical  inspection  was  succeeded  and  almost 
transposed  by  the  addition  of  the  visiting  nurses.  The  medical  inspection 
got  the  child  out  of  school,  and  the  visiting  nurse  got  the  child  back.  It 
seems  almost  foolish  to  have  medical  inspection  without  the  visiting  nurse. 
Not  that  we  would  abandon  the  medical  inspection;  in  no  sense  are  they 
rivals,  and  in  no  sense  is  the  nurse  to  make  a  diagnosis,  but  one  without  the 
other  is  insufficient  and  not  to  be  tolerated.  I  am  sure  that  here  in  Chicago 
we  are  working  toward  the  nurses  in  the  schools.  We  had  them  for  one 
halcyon  ten  weeks,  but  owing  to  lack  of  funds  and  political  difficulties,  the 
ten  weeks  were  all  we  were  able  to  get.1 

This  is  the  economic  aspect  of  the  nurse's  work.  There  is  another 
view  of  it  from  the  public-health  standpoint.  Miss  Lina  L.  Rogers 
says: 

Possibly  the  most  important  of  direct  results  and  the  most  far-reaching 
came  from  the  visiting  of  the  homes,  where  the  most  unsanitary  conditions 

1  American  Journal  of  Nursing  (1908). 


EDUCATIONAL  VALUE  OF  THE  NURSE  25 

were  discovered:  An  entire  family  using  the  same  towel  where  a  child  was 
excluded  from  school  with  contagious  eye  trouble;  cases  where  the  child  sent 
home  with  a  severe  form  of  scabies  was  helping  to  finish  and  carry  bundles  of 
sweat-shop  clothing;  filthy  yards  where  delicate  children  played;  patients 
in  the  last  stages  of  consumption,  living  and  sleeping  in  the  same  room  with 
the  family.1 

From  November  1,  1903,  to  May  12,  1904,  891  cases  of  contagious 
disease  that  had  not  been  reported  to  the  Board  of  Health  were  dis- 
covered in  the  homes  by  the  school  nurses. 

Dr.  Thomas  F.  Harrington,  of  Boston,  makes  a  point  of  this  in 
speaking  of  the  prevention  of  tuberculosis: 

The  school  nurse  has  opportunities  to  find  the  chronically  ill  which  are 
not  afforded  to  the  district  nurse,  the  dispensary  nurse,  nor  to  the  social 
worker.  All  of  these  enter  the  homes  after  the  case  of  tuberculosis  has  been 
discovered  or  reported.  The  school  nurse,  on  the  other  hand,  enters  the 
home  as  the  friend  of  the  children,  and  there  finds  often  the  advanced  case  of 
tuberculosis,  which  otherwise  would  have  gone  unrecognized  and  unreported 
until  death.  When  I  tell  you  that  the  thirty  school  nurses  in  the  Depart- 
ment of  School  Hygiene  of  Boston  have  visited  22,000  homes  of  school 
children  during  the  past  year,  some  magnitude  of  the  opportunities  afforded 
in  this  line  may  be  imagined.  I  would  urge  that  the  greater  part  of  our  efforts 
against  the  spread  of  tuberculosis  be  directed  toward  the  finding  and  the 
segregation  of  the  advanced  and  the  incurable  cases  of  this  disease.  Here 
lies,  I  believe,  the  greatest  hope  for  the  future.2 

Los  Angeles  was  the  second  city  in  the  United  States  to  adopt  the 
new  plan.  The  work  was  begun  by  the  Visiting  Nurse  Society  and 
taken  over  by  the  city,  three  nurses  being  appointed  for  eighty  schools. 

In  Seattle  two  nurses  in  six  months  visited  265  schools,  inspected 
15,947  pupils,  and  made  1,070  home  visits;  1,452  children  were  treated 
for  small  ailments  and  cured,  947  improved,  and  1,217  were  still  under 
treatment.  1,886  cases  were  reported  to  the  medical  inspectors,  397 
children  were  operated  on  for  the  removal  of  tonsils  and  adenoids,  294 
fitted  with  glasses,  and  out  of  461  cases  of  pediculosis,  416  were  cleaned 
up.  The  nurses  took  28  needy  children  to  physicians  or  orthopedic 
hospitals  to  be  cared  for. 

In  San  Francisco  in  1904,  Miss  Elizabeth  Ashe  and  Miss  Daisy 

1  Charities  and  the  Commons  (April  7,  1906),  69. 

2  Report  of  the  International  Congress  on  Tuberculosis  (Washington,  1908),  III, 
584. 


26  THE  NINTH  YEARBOOK 

Johnston  from  the  nurses'  settlement  worked  for  six  months  without 
remuneration,  in  the  hope  of  convincing  either  the  health  or  the  educa- 
tion authorities  of  the  necessity  of  some  kind  of  medical  inspection  in  the 
schools.  They  got  no  verbal  or  written  acknowledgment  of  their  serv- 
ices from  either  body,  but  were  more  than  repaid  by  the  appreciation 
of  the  teachers  and  children  and  the  improved  health  and  attendance 
of  the  latter.  When  the  Board  of  Health  put  physicians  in. the  schools, 
the  nurses  withdrew,  owing  to  the  complete  lack  of  interest  exhibited 
by  the  authorities.  School  nursing  was  however  established  in  1908 
with  a  staff  of  five  nurses.1 

In  Chicago,  Detroit,  Philadelphia,  Grand  Rapids,  Washington, 
Seattle,  and  other  cities  the  work  was  begun  voluntarily  by  the  local 
visiting  nursing  associations,  and  later  taken  over  more  or  less  com- 
pletely by  the  Board  of  Education  or  the  Board  of  Health.  In  Phila- 
delphia, Miss  Anna  Stanley  has  done  rare  pioneer  work  in  the  interests 
of  school  nursing.  The  Visiting  Nurse  Society  offered  her  services  and 
she  was  detailed  to  four  downtown  schools.  Through  her  efforts,  in 
four  months  contagious  skin  diseases  were  eradicated  from  these  schools, 
and  filth  conditions  were  greatly  reduced.  Dr.  Newmayer,2  one  of  the 
most  progressive  of  the  medical  inspectors  in  Philadelphia,  says  of  her 
work: 

The  percentage  of  pediculosis  existing  in  the  schools  where  the  nurse  began 
her  work  in  April,  1904,  was  30  per  cent.  This  has  been  reduced  to  8  per 
cent.  This  is  due  to  the  influence  of  the  nurse  at  the  homes.  Conjunctivitis 
and  corneal  ulcers  received  no  attention  from  parents  and  were  treated  only 
after  the  children  were  taken  in  charge  by  the  nurse.  They  were  soon  cured 
and  the  children  able  to  resume  studies.  These  cases  included  several  in 
which  corneal  ulcer  threatened  the  sight.  Weak,  anaemic  children,  unable  to 
work  or  study,  due  to  impoverishment  from  improper  or  no  food,  were  visited 
in  their  homes  and  the  existing  difficulties  corrected.  Over  200  children 
with  bad  defective  vision  were  treated  and  supplied  with  necessary  glasses 
only  through  much  persuasion  and  the  persistent  efforts  of  the  nurse.  This 
often  required  many  home  visits.  The  above  reports  show  the  remarkable 
results  of  medical  inspection;  but  it  requires  the  trained  nurse  to  lend  assur- 

1  E.  M.  Hickey,  Nurses'  Journal  of  the  Pacific  Coast  (October,  1908);  Elizabeth 
H.  Ashe,  ibid.  (May,  1908). 

2  S.  W.  Newmayer,  M.D.,  "Trained  Nurses  in  the  Public  Schools  as  a  Factor 
in  the  Education  of  the  Children,"  American  Journal  of  Nursing  (December,  1906), 
185;  "System  Employed  by  the  Trained  Nurse  in  the  Schools  of  Philadelphia," 
ibid.,  (January,  1907),  254. 


EDUCATIONAL  VALUE  OF  THE  NURSE  27 

ance  that  the  advice  given  by  the  physician,  in  the  cases  he  examines  patiently 
day  by  day,  is  not  thrown  away.  The  medical  inspector  has  accomplished 
much,  but  only  with  the  trained  school  nurse,  and  her  individual  care,  per- 
sonal inquiry  and  knowledge  of  home  life,  is  the  highest  degree  of  efficiency 
in  education  procured. 

Dr.  Witmer  of  the  Psychological  Clinic  in  Philadelphia,  who  has 
employed  Miss  Stanley's  services  in  his  hospital  school  for  defective 
children,  says  of  her  that  "if  the  school  nurse  becomes  an  accepted 
institution  in  the  Philadelphia  schools,  it  will  be  largely  owing  to  her 
pioneer  work,  and  to  the  support  given  the  work  by  the  Visiting  Nurse 
Society."  She  started  in  1904.  In  1908,  six  school  nurses  were 
appointed  by  the  Board  of  Education  in  Philadelphia. 

It  will  be  noted  that  in  America  and  also  in  England,  the  initiative 
has  usually  come,  not  from  the  school  board  or  often  from  the  board  of 
health,  but  from  organizations  or  individuals  outside  the  school.  In 
many  cases  physicians  have  volunteered  their  services  as  consultants 
and  occasional  visitors  for  longer  or  shorter  periods.  In  Miss  Waters' 
recent  work  on  Visiting  Nursing  in  the  United  States,  the  records  show 
very  clearly  that  in  most  of  the  cities  in  the  United  States  where  school 
nursing  has  been  established,  the  first  move  has  been  made  by  nursing 
organizations  supported  by  private  subscriptions.  In  many  cases 
they  are  still  carrying  it  on,  often  with  little  official  recognition  or 
co-operation,  but  with  hope  of  the  ultimate  conversion  of  the  authorities. 
In  some  places  the  work  was  started  by  a  charity  organization  society, 
in  others  by  a  church,  a  woman's  club,  a  fathers'  and  mothers'  club,  or  a 
settlement;  in  one  case  a  publishing  company  (The Delineator)  supported 
several  school  nurses.  It  is  but  fair  to  say  that  the  hesitation  on  the 
part  of  boards  of  education  is  due  not  so  much  perhaps  to  indiffer- 
ence, as  to  the  inadequacy  of  the  educational  exchequer  and  a  conflict 
of  opinion  as  to  what  is  the  most  immediate  need.  Sometimes  it  is  due 
to  a  misunderstanding  of  the  real  purpose  of  school  nursing.  In  a  paper 
on  "The  Visiting  Nurse  in  a  Small  City,"  Miss  Crane,  of  Kalamazoo, 
Mich.,  writes: 

Some  time  ago  we  applied  for  permission  for  our  district  nurse  to  under- 
take nursing  in  one  of  the  public  schools,  thinking  that  if  it  proved  a  success 
we  would  endeavor  to  procure  two  nurses  and  do  nursing  in  several  of  the 
schools,  and  that  we  would  be  able  to  give  more  careful  attention  also  to  the 
matter  of  tuberculosis.  Permission  was  denied  us,  because  of  a  plan  in  the 
mind  of  a  member  of  the  school  board  to  introduce  medical  inspection  by 


28 


THE  NINTH  YEARBOOK 


physicians  next  year.    We  feel  that  even  were  there  regular  medical  inspec- 
tion, the  visiting  nurse  is  still  a  necessity  to  further  the  work  of  the  physician.1 

This  whole  work  of  visiting  nursing,  which  has  been  so  successful 
in  Kalamazoo,  was  undertaken  by  the  Woman's  Civic  Improvement 
League  of  that  city.  There  is  no  organized  National  District  Nursing 
Association  in  America  to  cover  the  small  towns  and  the  remoter  dis- 
tricts. In  England,  Scotland,  and  Ireland,  where  there  is  such  a  large 
organization  established  by  the  late  queen  and  generously  endowed  in 
her  memory,  both  city  and  country  are  well  supplied  with  "queen's 
nurses."  These  district  nurses  have  done  much  to  provide  more  or 
less  regular  care  and  attention  to  the  needs  of  school  children,  as  well 
as  to  the  poor  in  their  homes.  In  Canada,  the  Victorian  Order,  a  simi- 
lar organization,  has  also  done  something  toward  establishing  school 
nursing  in  two  or  three  of  the  larger  cities. 

When  Miss  Waters'  book  was  published  in  1909,  the  following  cities 
in  the  United  States  had  more  or  less  complete  systems  of  school  nursing.2 
MUNICIPALITIES  EMPLOYING  PUBLIC-SCHOOL  NURSES 


State 

City 

Under  Department  of 

Estab- 
lished 

No.  of 
Nurses 

California 

California 

California 

Colorado 

Berkeley 

Los  Angeles 

San  Francisco 

Pueblo 

Atlanta 

Chicago 

Des  Moines 

Baltimore 

Boston 

Brookline 

Cambridge 

Detroit 

Grand  Rapids 

Jersey  City 

Orange 

New  York 

Syracuse 

Cincinnati 

Cleveland 

Portland 

Harrisburg 

Philadelphia 

Seattle 

Tacoma 

Board  of  Education 
Board  of  Health 
Department  of  Health 
Department  of  Education 
Department  of  Education 
Department  of  Health 
Board  of  Education 
Department  of  Health 
Department  of  Education 
Department  of  Education 
Department  of  Health 
Board  of  Health 
Board  of  Education 
Board  of  Health 
Board  of  Education 
Department  of  Health 
Board  of  Health 
Board  of  Health 
Board  of  Education 
City  of  Portland 
Board  of  Education 
Board  of  Education 
Board  of  Education 
Board  of  Education 

1909 
1903 
1908 
1909 
1909 
1908 
I9°S 
I905 
1 9°S 
1909 
1907 
1906 

1 90S 
1907 
1906 
1902 
1908 
1909 
1908 
1908 
1908 
1908 
1908 
1908 

I 

4 

4 

1 

Georgia 

1 

Illinois 

41 

Iowa 

2 

Maryland 

Massachusetts.  .  .  . 
Massachusetts.  .  .  . 
Massachusetts .... 
Michigan 

S 
34 

1 
1 
2 

Michigan 

3 

New  Jersey 

New  Jersey 

New  York 

New  York 

Ohio 

2 
2 
141 
2 
2 

Ohio 

2 

Oregon 

1 

Pennsylvania 

Pennsylvania 

Washington 

Washington 

1 
6 
2 

1 

1  Caroline  Bartlett  Crane,  Charities  and  the  Commons  (April  7,  1906). 

2  Visiting  Nursing  in  the  United  States,  367. 


EDUCATIONAL  VALUE  OF  THE  NURSE  20 

THE    FUNCTIONS    OF    THE    SCHOOL    NURSE    AND    VARIOUS    ESTIMATES    OF 

HER    VALUE 

The  functions  of  the  school  nurse  vary  widely,  each  city  or  town 
working  out  its  own  system  according  to  its  needs  and  the  special  fea- 
tures of  its  organization.  The  question  of  expense  is  probably  the 
largest  determining  factor.  Some  of  these  functions  may  be  mentioned 
briefly. 

a)  Assistant  to  the  school  doctor  in  his  visits  of  inspection — pre- 
paring children  for  examination,  recording  data,  testing  vision,  hearing, 
etc. 

b)  Routine  daily,  weekly,  or  monthly  inspection  in  classrooms. 

c)  Keeping  of  records,  sending  out  reports  to  parents,  cards  to 
principals,  etc. 

d)  Treatment  of  routine  cases  in  the  school — bathing  eyes,  irri- 
gating ears,  dressing  wounds,  etc. 

e)  Emergency  service — caring  for  accidents,  fainting,  convulsions, 
etc. 

/)  Instruction  of  children  in  personal  hygiene  and  sanitation — 
practical  demonstrations  and  talks. 

g)  Follow-up  work  in  the  homes — notifying  physicians,  instruction 
of  mothers  in  the  care  of  children,  taking  children  to  dispensaries, 
dental  clinics,  etc.,  for  treatment,  when  necessary. 

h)  Sanitary  inspection  of  homes — discovering  and  reporting  con- 
tagious diseases  to  Board  of  Health. 

i)  Reporting  of  truancy  cases. 

j)  Teachers'  and  mothers'  meetings. 

k)  Summer  work  in  prevention  of  infant  mortality — playground 
supervision,  fresh-air  excursions,  etc. 

In  no  one  system  are  all  these  functions  incorporated.  Indeed, 
the  staff  of  nurses  is  usually  so  entirely  inadequate  that  only  the  most 
needy  and  pressing  cases  can  be  attended  to.  Some  authorities  con- 
sider one  feature  of  the  work  of  surpassing  importance,  others  emphasize 
quite  a  different  feature.  But  so  far  as  the  literature  on  the  subject 
may  be  trusted,  there  seem  to  be  no  two  opinions  regarding  the  value 
of  the  nurse's  work.  Doctors,  teachers,  social  workers,  parents,  and 
children  are  almost  unanimous  in  their  approval,  and  the  best  part  of 
it  is  that  the  nurses  themselves  are  enthusiastic  over  its  possibilities. 

It  may  be  well  to  quote  here  the  opinions  of  a  few  additional  authori- 


30  THE  NINTH  YEARBOOK 

ties  on  the  subject.  The  school  physicians  are  the  ones  who  ought  to 
know  best  whether  the  nurse  has  made  good  in  the  field  of  health 
inspection.  Dr.  Newmayer,  of  Philadelphia,  has  written  much  on  this 
phase  of  medical  inspection. 

The  results  obtained  with  little  friction  among  doctor,  nurse,  the  parent, 
and  school  teachers,  are  the  best  evidence  of  the  success  of  our  system 

The  weak  point  in  medical  inspection  lies  in  the  fact  that  it  brings  to  light 
conditions  over  which  we  can  have  very  little  control.  We  cannot  alter  the 
home  environment  or  compel  attention  to  any  directions  given.  It  is  possible 
however  to  influence  and  instruct  at  the  homes,  and  this  can  be  best  effected 
by  the  aid  of  a  well-trained  nurse.  I  look  upon  the  services  of  a  nurse  as  one 
of  the  most  essential  factors  in  any  system  of  medical  inspection 

There  are  various  problems  to  be  solved  in  each  case  and  the  nurse  invari- 
ably finds  the  remedy.  The  duties  of  the  school  nurse  assure  success  to  the 
work  of  the  medical  inspector  in  improving  the  health  of  the  school  children. 

Dr.  Helen  C.  Putnam,  whose  work  in  medical  sociology  is  so  well 
known,  in  an  address  given  at  the  Second  International  Congress  of 
School  Hygiene,  London,  remarks: 

Medical  inspection  instructs  indirectly  but  forcefully  by  drawing  atten- 
tion of  pupils,  parents,  and  the  public  to  communicable  diseases;  to  care  of  the 
person,  general  health  and  development;  to  school  furnishings,  lighting,  ven- 
tilation, and  playgrounds;  but  instructs  most  efficiently  where  school  nurses 
are  employed.  It  means  much  in  two  of  our  largest  cities  where  from  fifty 
to  eighty  thoroughly  trained  nurses  not  only  attend  to  the  minor  ailments  at 
the  schools,  but  daily  radiate  therefrom  into  homes,  showing  mothers  details 
of  cleaning,  feeding,  clothing  children  and  of  caring  for  the  premises.  The 
immediate  result  observed  is  that  the  pupils  sent  from  school  by  the  physician 
return  sooner  and  in  better  condition,  and  that  many  otherwise  unknown 
wrongs  to  childhood  are  reported  to  proper  authorities  for  correction.1 

It  is  interesting  to  note  the  change  in  the  textbooks  on  school  hygiene 
within  the  last  few  years.  In  Medical  Inspection  of  School  Children,2 
published  in  1904,  there  is  a  most  thorough  treatment  of  the  subject 
of  physical  examinations,  anthropometry  tests,  etc.,  and  the  authors 
show  the  new  social  standpoint  in  their  recommendations  for  the  inves- 
tigation of  housing  conditions,  the  economic  and  wage-earning  capacity 
of  the  parents,  the  healthiness  or  unhealthiness  of  local  occupations, 

1  Report  of  Second  International  Congress  of  School  Hygiene,  924. 

2W.  L.  MacKenzie,  M.D.,  and  Edwin  Matthew,  Medical  Inspection  of  School 
Children. 


EDUCATIONAL  VALUE  OF  THE  NURSE  31 

conditions  determining  food-supply,  of  the  feeding  of  infants,  of  the 
nurture  of  mothers  before  and  after  child-birth,  and  of  many  other 
conditions,  customs,  etc.,  which  so  directly  influence  the  health  of  school 
children  and  of  the  race.  But  while  they  recommend  women  sanitary 
inspectors  for  some  of  this  work,  only  in  one  brief  note  describing  the 
New  York  system  do  they  mention  nurses.  They  define  the  function 
of  medical  inspection,  as  the  collecting  of  data  as  a  basis  for  correct 
inductions,  rather  than  the  actual,  immediate  remedying  of  conditions. 

More  recent  writers  go  farther,  and  in  most  of  the  works  published 
within  the  last  four  years  one  chapter  or  more  is  devoted  to  the  school 
nurse.     A.  H.  Hogarth,1  of  London,  writing  in  1909,  says: 

The  school  nurse  represents  as  new  an  idea  in  the  school  world  as  the 
school  doctor.  She  is  not  a  nurse  in  the  usual  acceptation  of  the  term,  but  a 
woman  who  has  had  the  scientific  training  of  a  nurse.  On  the  other  hand 
she  is  not  merely  a  sanitary  inspector  or  a  health  visitor.  She  is  an  educa- 
tion officer  employed  by  an  educational  authority  for  certain  routine  medical 
duties  in  connection  with  education.  As  in  the  hospital,  so  in  the  school,  she 
is  the  doctor's  assistant  and  works  under  his  direction. 

In  Civics  and  Health,  published  in  1908,  Dr.  Allen  repeatedly  empha- 
sizes the  value  of  the  nurse,  not  only  in  the  school  but  in  almost  all 
kinds  of  social-service  work.  Here  he  speaks  particularly  of  an  inves- 
tigation by  the  Bureau  of  Municipal  Research  in  New  York  to  deter- 
mine the  reason  for  the  ineffectiveness  of  medical  inspection,  under  the 
older  regime.  Where  home  visiting  was  established — 
the  net  average  result  of  a  day's  work  by  a  nurse  was  the  actual  treatment 
of  over  five  children,  three  of  them  completely,  and  two  of  them  for  one  or 
more  defects,  sixty  cents  per  child! 

Having  established  the  willingness — even  eagerness — of  parents  to  do  all 
in  their  power  to  remove  defects  that  handicapped  their  children,  it  was 
obviously  the  duty  of  the  health  department  so  to  organize  its  work  that  it 
could  insure  the  education  of  parents. 

So  conclusive  were  the  results  of  follow-up  work  efficiently  supervised  by 
the  Department  of  Health,  that  school  officials  are,  for  the  present,  inclined  to 
waive  the  demand  for  the  transfer  of  physicians  and  nurses  to  the  Board  of 
Education,  and  to  substitute  education  for  compulsion  with  parents  who 
obstinately  refuse  to  take  proper  remedial  measures  for  their  children  when 
reported  defective.2 

1  A.  H.  Hogarth,  M.B.,  Medical  Inspection  of  Schools,  chap,  xii,  p.  172.      / 

2  W.  H.  Allen,  Civics  and  Health,  299-300. 


32  THE  NINTH  YEARBOOK 

Ralph  H.  Crowley,  M.D.,  writing  of  the  "Hygiene  of  School  Life" 
in  1 910,  quotes  the  Board  of  Education  of  London  as  reporting  that  they 

are  satisfied  that  this  work  offers  a  great  field  of  valuable  service  for  the  school 
nurse,  and  they  recommend  that  wherever  practicable,  education  authorities 
should  secure,  especially  in  rural  districts,  the  benefit  and  true  economy  which 
may  thus  be  obtained.1 

He  further  states  that 

the  two  main  requirements  of  medical  inspection  are:  first,  that  children 
should  receive  treatment;  and  secondly,  that  the  treatment  should  be  ade- 
quate. 

The  writer's  own  experience  in  the  past  has  been  that  not  more  than 
about  one-third  of  the  parents  notified  have  paid  attention  to  such  notices, 
and  the  reason  undoubtedly  in  many  cases  is  because  the  parents  do  not 
believe  that  the  defects  are  such  as  are  worth  troubling  about.  The  further 
opportunities  now  available  for  making  inspection  and  reinspection  more 
thorough,  for  interviewing  parents  or  sending  a  nurse  or  health  visitor  around 
to  the  home,  will  undoubtedly  lead  to  a  much  larger  number  of  children  receiv- 
ing attention  than  heretofore.2 

The  superintendent  of  schools  of  Los  Angeles,  Cal.,  writes  that  one 
school  nurse,  through  her  untiring  efforts,  has  created  a  sentiment  of 
cleanliness  not  only  among  the  scholars  but  among  the  families  in 
certain  sections  of  the  city. 

In  Medical  Inspection  of  Schools,  published  in  1908,  the  work  is  pre- 
sented from  the  standpoint  of  both  the  physician  and  educationalist. 

To  sum  up  the  case  for  the  school  nurse — she  is  the  teacher  of  the  parents, 
the  pupils,  the  teachers,  and  the  family  in  applied  practical  hygiene.  Her 
work  prevents  loss  of  time  on  the  part  of  the  pupils  and  vastly  reduces  the 
number  of  exclusions  for  contagious  diseases.  She  cures  minor  ailments  in 
the  school  and  furnishes  efficient  aid  in  emergencies.  She  gives  practical 
demonstrations  in  the  home,  of  required  treatments,  often  discovering  there 
the  source  of  the  trouble,  which,  if  undiscovered,  would  render  useless  the 
work  of  the  medical  inspector  in  the  school.  The  school  nurse  is  the  most 
efficient  possible  link  between  the  school  and  the  home.  Her  work  is  immensely 
important  in  its  direct  results  and  very  far-reaching  in  its  indirect  influences. 
Among  foreign  populations  she  is  a  very  potent  force  for  Americanization.3 

1  R.  H.  Crowley,  Hygiene  of  School  Life. 

2  Ibid.,  163-64. 

3  Gulick  and  Ayres,  Medical  Inspection  of  Schools,  80. 


EDUCATIONAL  VALUE  OF  THE  NURSE  S3 

ATTITUDE   OF   TEACHERS  TO   SCHOOL  NURSING 

As  might  be  expected  the  teachers  were  not  all  at  first  favorable  to 
the  new  plan.     Hogarth  says: 

The  functions  of  a  school  nurse  are  likely  to  be  extended  in  many  direc- 
tions, but  if  the  teachers  are  not  in  harmony  with  the  work,  difficulties  will 
inevitably  arise.  Experience  in  London,  however,  has  shown  that  the  major- 
ity of  teachers,  so  far  from  objecting  to  the  nurse,  have  constantly  asked  for 
more  frequent  visits  and  have,  from  the  first,  taken  a  pride  and  interest  in 
the  cleanly  condition  of  the  children  attending  their  schools.  Such  co-opera- 
tion is  essential  for  a  satisfactory  and  efficient  school  nursing  service.1 

The  following  is  the  testimony  of  a  school  nurse: 

At  first  a  number  of  school  teachers,  and  even  principals  objected,  but  a 
very  short  time  served  to  show  that  these  could  be  classified  into  three  groups. 
Those  who  did  not  understand  just  what  school  nursing  meant  and  feared 
that  it  would  result  in  interfering  with  the  school  routine  or  lower  the  attend- 
ance, when  convinced  that  such  was  not  the  case  became  ardent  advocates 
of  it.  Next  came  those  who  feared  that  part  of  the  funds  necessary  to  main- 
tain the  work  were  to  be  deducted  from  the  already  slender  appropriation  of 
the  Board  of  Education. 

The  third  group  consisted  of  those  who  were  old-fashioned  and  firmly 
believed  that  measles,  scarlet  fever,  and  diphtheria  were  dispensations 
of  Providence,  which  everyone  had  to  bear  sooner  or  later,  and  the 
sooner  we  had  them  and  got  over  it  the  better;  also  that  pediculi,  ring- 
worm, impetigo,  and  scabies  were  afflictions  of  childhood,  unpleasant 
to  be  sure,  but  not  to  be  avoided.  The  members  of  this  group  with- 
drew into  their  shells,  as  it  were,  and  dismissed  the  whole  subject  of 
medical  inspection  as  one  more  "fad"  which  had  to  be  thrust  upon  them. 
They  neither  assisted  nor  hindered,  they  simply  ignored.  They  saw 
none  of  the  good  accomplished,  but  mentally  filed  for  future  reference 
any  mistake  or  unpleasantness  which  occurred. 

Lastly  (and  to  their  credit  this  group  was  extremely  small)  came  a 
few  narrow7  individuals  who  felt  that  the  school  and  all  it  contained  was 
their  personal  property,  and  that  any  person  coming  into  it  must  neces- 
sarily be  guided  by  what  they  thought.  They  preferred  to  say  whether 
a  child  should  be  excluded  or  readmitted  to  school ;  what  rooms  routine 
inspection  should  be  done  in,  and  how  frequently.  In  short,  they 
wished  to  conduct  the  medical  inspection  of  the  pupils,  not  according 

1  Hogarth,  Medical  Inspection  in  Schools,  186. 


34  THE  NINTH  YEARBOOK 

to  the  ideas  of  the  medical  inspectors  and  school  nurses,  whose  pro- 
fessional training  qualified  them  for  the  work,  but  according  to  their 
own  personal  whims  and  fancies.1  Most  of  the  school  nurses  however 
speak  with  the  greatest  appreciation  of  the  co-operation  of  teachers 
and  principals  in  their  work. 

ATTITUDE   OF   CHILDREN  AND  PARENTS 

The  appreciation  of  the  children  is  often  amusing  and  always  grati- 
fying. They  become  very  much  attached  to  the  school  nurse  and  some- 
times invent  the  most  impossible  ailments  so  they  may  consult  with 
her.  Every  child  loves  to  be  mothered  and  a  nurse  should  be  essen- 
tially "a  mother."  They  have  the  greatest  faith  in  her  powers.  A 
little  boy  in  Liverpool  was  found  dragging  his  infant  brother  along  to 
the  school  "to  get  the  lady  to  cure  his  eyes."  When  the  school  nurse 
visits  the  homes,  they  all  crowd  around  her,  bringing  their  babies  for 
her  inspection,  and  insisting  that  she  visits  every  sick  man,  woman, 
and  child  in  the  tenement  or  in  the  street. 

The  parents  are  not  always  so  easily  dealt  with.  One  meets  every- 
where the  unalterable  conviction  that  dirt  is  healthy,  vermin  inevitable, 
and  sickness  just  luck.  The  mother  who  knows  all  about  ringworm 
because  all  her  children  had  it  and  persists  that  "if  they  are  to  git  it, 
they  will  git  it,"  is  not  easily  convinced  of  the  possibility  of  its  absolute 
prevention.  She  "  don't  'old  with  fightin'  Providence,"  but  pins  her  faith 
to  the  good  old  treatment  of  "hink  and  tobacco  hash."  Some  mothers 
object  to  all  this  fuss  about  cleanliness  because  they  "don't  want 
their  children  to  get  too  high-toned."  Another  knows  that  if  we  were 
intended  to  wear  glasses  we'd  be  born  with  them,  and  presents  the  unan- 
swerable argument  that  "if  adenoids  are  not  good  for  people,  why  were 
they  put  there?"  They  have  an  astonishing  faith  in  the  gospel  of 
"things  as  they  are."  The  foreigners  are  often  suspicious  and  seem  to 
be  unable  to  grasp  the  idea  of  any  person  doing  anything  for  them  merely 
from  a  desire  to  help  them.  The  men,  who  have  some  little  acquaintance 
with  the  ways  of  the  street,  are  willing  to  bet  anything  that  the  doctors 
and  nurses  are  getting  something  out  of  this  thing  "on  the  side."  But 
the  mother  who  meets  the  nurse  with  a  perfect  torrent  of  abuse  and 
declares  with  much  emphasis  that  she  never  will  allow  anyone  "to  take 

1  C.  R.  Kefauver,  "Obstacles  in  the  Path  of  the  School  Nurse,"  American  Jour- 
nal of  Nursing  (August,  1909). 


EDUCATIONAL  VALUE  OF  THE  NURSE  35 

out  Johnny's  eyes  and  scrape  'em,"  is  quite  mollified  when  she  knows 
the  real  reason  and  extent  of  the  operation,  and  ends  by  inviting  the 
nurse  to  "stay  to  tea." 

The  work  requires  endless  tact,  patience,  and  real  sympathy  with, 
and  understanding  of,  the  people.  Miss  A.  W.  Kerr,  who  directs  the 
work  in  New  York,  says: 

There  are  many  pitfalls  in  the  way.  The  nurse  must  not  diagnose  cases, 
she  must  not  interfere  with  any  physician's  practice,  she  must  not  antagonize 
the  family,  and  she  must  know  their  language,  understand  their  customs, 
and  respect  their  pride.  She  must  see  that  defects  are  corrected,  glasses 
supplied,  that  tea  and  coffee  are  cut  out  of  a  child's  diet  and  milk  and  eggs 
substituted. 

She  is  always  running  up  against  difficult  situations,  national  pre- 
judices, and  national  customs.  To  deal  with  these  wisely  requires  no 
small  knowledge  of  psychology  and  sociology,  as  well  as  a  practical 
insight  into  actual  conditions. 

It  is  all  very  well  to  say  in  general,  give  meat  or  milk  or  eggs,  but  when 
these  articles  are  seldom  or  never  used,  it  is  better  to  say  to  an  Italian  mother, 
"Give  to  Theresa  less  spaghetti  and  more  oil,"  or  to  a  Russian  one,  "Do  not 
let  Katia  have  so  much  kale,  but  give  her  plenty  of  noodles."  That  is  prac- 
tical advice  and  is  likely  to  be  followed. 

In  persuading  the  parent  to  attend  to  such  defects  as  adenoids,  bad 
vision,  etc.,  the  wise  visitor  studies  the  dominant  national  traits  of  each 
group  and  appeals  to  these.  In  an  American  community  it  is  national 
pride — the  desire  to  have  the  American  child  equal,  if  not  superior,  to 
every  other.  In  a  Swedish  community  it  would  be  shown  that  removal 
of  physical  defects  renders  a  child  brighter  and  more  successful  in  life. 
In  a  Jewish  district,  the  ultimate  saving  in  increased  earning  capacity 
that  results  from  better  health,  and  the  great  financial  waste  of  sickness 
is  the  dominant  argument.  Above  all,  the  public  needs  to  be  constantly 
educated  in  one  thing — that  is,  that  it  as  tax-payer  is  maintaining  the. 
boards  of  education  and  of  health,  and  that  it  has  the  greatest  reason 
for  demanding  the  highest  interest  on  capital  invested. 

But  the  results  are  on  the  whole  encouraging,  and  the  nurses  see  the 
fruits  of  their  labors,  and  receive  much  real  gratitude.  The  following 
is  one  of  the  hundreds  of  such  testimonies: 

Der  Nurs:  I  lov  yu  becos  yu  mak  wel  mi  mary.  It  is  gud  dat  de  schul 
has  such  a  gud  womin  to  luk  after  de  childen.  mi  usband  tanks  yu  to.  God 
bles  yu. 


36  THE  NINTH  YEARBOOK 

SCHOOL  NURSING  IN  RELATION   TO   THE  MEDICAL  PROFESSION 

The  family  physician  has  resented  the  offices  of  the  school  nurses  in 
some  cases  on  the  ground  that  they  defraud  him  of  his  rightful  practice. 
This  is  not  perhaps  without  some  reason.  It  is  very  hard  for  her  to 
know  always  when  a  family  is  able  to  pay  for  treatment  and  when  the 
child  ought  to  be  taken  to  the  dispensary.  Then  professional  grafters 
have  been  known  to  invade  even  a  system  of  medical  inspection,  using 
their  office  to  secure  patronage  either  for  themselves  or  their  friends. 
Here  between  her  rigid  code  of  professional  ethics  and  her  desire  to  do 
the  best  for  the  child  and  the  family,  the  nurse  is  surely  in  a  difficult 
position. 

It  is  an  old  tradition,  fostered  by  the  military  system  under  which 
trained  nursing  came  into  being,  that  the  nurse's  first  and  only  duty 
is  to  obey  orders.  The  doctor  is  the  captain  and  she  is  the  private,  and 
she  is  there  not  to  question  nor  even  to  understand  his  mandates,  but 
simply  to  do  what  she  is  told.  There  are  still  many  physicians  who 
hold  that  obedience  is  the  only  requisite  in  a  nurse,  and  who  jealously 
oppose  any  system  of  training  or  any  plan  for  raising  educational  stand- 
ards which  might  give  her  a  broader  understanding  of  her  problem,  and 
thus  increase  the  scope  of  her  labors.  Such  men  are  filled  with  appre- 
hension at  the  powers  which  are  being  placed  in  the  hands  of  the  school 
nurse,  particularly  in  the  detection  of  pathological  symptoms  and 
abnormalties,  which  they  consider  to  be  really  the  assumption  of  her 
ability  to  diagnose  disease. 

It  may  as  well  be  emphatically  stated  that  it  is  no  part  of  the  school 
nurse's  plan  to  supplant  the  doctor  either  in  the  school  or  the  home. 
She  is  there  to  supplement  him,  to  carry  out  his  instructions,  and  to 
see  that  they  are  made  effective.  But  she  does  more  than  this,  as  has 
been  shown;  her  function  in  the  school  is  largely  a  social  and  educa- 
tional one.  She  does  not  covet  the  field  of  medical  practice;  her  own 
field  is  an  ample  one,  rich  in  opportunities,  wonderful  in  its  possibilities, 
and  fruitful  in  its  results.  It  offers  scope  for  all  her  highest  faculties, 
and  presents  large  problems  for  investigation,  for  development,  and 
adjustment. 

Some  of  the  difficulties  encountered  are  doubtless  due  to  the  nurse  her- 
self. She  has  not  always  been  the  best  person  for  her  place,  and  neither 
her  school  nor  her  hospital  training  has  fitted  her  fully  for  her  work  in  this 
new  social  field.     She  herself  is  in  process  of  evolution,  and  only  as  she 


EDUCATIONAL  VALUE  OF  THE  NURSE  37 

adapts  herself  to  the  special  needs  of  the  situation  has  she  any  hope  of 
ultimate  survival.  I  have  attempted  to  show  by  the  history  of  medical 
inspection  that  the  visiting  nurse  has  done  this  in  a  rather  effective  way 
in  school  nursing,  and  that  she  is  the  logical  person  for  any  such  work. 
But  this  is  not  to  say  that  all  nurses  are  fitted  to  be  school  nurses,  any 
more  than  all  teachers  are  fitted  to  be  kindergartners. 

Many  nurses  are  essentially  doers  and  not  teachers,  many  do  not 
care  particularly  for  children,  others  grumble  at  the  routine  of  school 
work,  and  prefer  the  more  varied  and  strenuous  experiences  of  hospital 
or  district  work  or  the  more  lucrative  service  of  private  nursing.  A 
more  careful  selection  of  school  nurses  on  the  ground  of  personal  qualifi- 
cations and  professional  training  would  obviate  many  difficulties. 

OTHER  TYPES  OF  SCHOOL  WORK  IN  WHICH  NURSES  ARE  ENGAGED 

It  is  not  only  in  the  ordinary  school,  however,  that  the  visiting  nurse 
comes  into  contact  with  the  children  and  demonstrates  her  value  as  a 
teacher  and  promoter  of  health.  In  open-air  schools  for  anaemic, 
tubercular,  or  convalescent  children,  she  is  employed  in  more  strictly 
nursing  duties,  seeing  that  the  little  patients  are  warmly  clad,  watching 
for  signs  of  fatigue,  attending  to  matters  of  diet,  etc.  In  schools  for 
defectives  and  cripples,  in  institutions  for  the  blind,  in  reformatories 
and  all  such  institutions  where  the  physical  condition  is  so  often  the  key 
to  mental  and  moral  improvement,  nurses  are  employed  in  increasing 
numbers.  In  the  home  and  school  visiting  work  undertaken  by  the 
Public  Education  Association  of  New  York,  it  happened  last  year  that 
three  out  of  five  of  the  visitors  appointed  had  been  district  nurses. 
Their  duties  did  not  primarily  relate  to  health  at  all,  but  it  is  found  that 
the  wide  practical  training  of  the  visiting  nurse  gives  her  social  insight 
and  an  easy  entrance  into  the  homes.  It  might  be  added  that  two  at 
least  of  these  nurses  had  been  formerly  teachers,  not  at  all  an  unusual 
combination  among  nurses.  This  makes  them  as  much  at  home  in  the 
schoolroom  as  the  hospital  ward  or  the  sick  room,  and  makes  an  excel- 
lent basis  for  the  specialized  training  in  psychology  and  sociology  which 
is  needed  for  work  with  defective  and  delinquent  children.  Dr.  Wit- 
mer  speaks  of  the  great  value  of  such  a  teacher-nurse  employed  in  his 
hospital  school  for  defective  children  in  Philadelphia.1 

1  Lightner  Witmer,  Ph.D.,  "The  Hospital  School,"  Psychological  Clinic  (October 
15.  1907)- 


38  THE  NINTH  YEARBOOK 

Some  of  the  large  residential  schools  and  colleges  now  engage  a 
trained  nurse  to  attend  the  cases  of  illness,  but  it  is  significant  that 
emphasis  is  being  laid  more  and  more  on  the  preventive  rather  than  the 
ameliorative  aspect  of  her  work,  so  that  she  is  really  a  supervisor  of 
health  in  the  dormitories.  Statistics  show  a  marked  decrease  in  small 
ailments  and  in  contagious  diseases,  and  an  improvement  in  the  general 
health  of  the  school  body,  where  this  work  has  been  carried  on  intelli- 
gently and  faithfully. 

TUBERCULOSIS   WORK 

Some  mention  should  be  made  of  other  activities  where  nurses  are 
engaged,  which  touch  the  educational  problem  rather  intimately.  The 
societies  for  the  prevention  of  tuberculosis  are  convinced  that  if  they 
can  only  teach  the  school  children  the  practical,  vital  principles  of 
sanitation  and  the  simple  facts  about  tuberculosis,  it  will  be  a  most 
important  contribution  to  the  suppression  of  a  world  plague.  Very 
little  can  be  done  with  the  mothers  and  fathers  whose  habits  are  more 
or  less  fixed  and  who  on  account  of  fatigue  or  despair  or  simple  indiffer- 
ence have  lost  the  power  of  readily  assimilating  new  ideas.  But  the 
children  are  alert  and  impressionable,  and  their  co-operation  is  easily 
secured.  In  some  cities  from  30  per  cent  to  50  per  cent  of  the  school 
children  are  already  infected  with  tuberculosis  and  in  all  schools  many 
will  inevitably  contract  the  disease.  Dr.  Farrand  says  at  the  lowest 
estimate  there  are  now  in  the  schools  of  the  United  States  150,000 
children  who  have  well-marked  symptoms  of  tuberculosis.  The  appli- 
cation of  a  few  simple  hygienic  and  sanitary  rules  would  save  a  great 
number  of  those  children.  If  they  can  only  be  made  to  feel  the  impor- 
tance of  the  problem,  there  is  hope  that  the  homes  of  the  future  at  least 
will  be  made  comparatively  safe. 

In  Pittsburgh  and  Cincinnati  where  the  anti-tuberculosis  propa- 
ganda is  particularly  active,  a  nurse  is  employed  for  the  public-school 
work.  With  the  permission  of  the  school  board  and  the  co-operation 
of  principals  and  teachers,  she  arranges  for  talks  in  every  schoolroom 
or,  in  some  cases,  for  larger  groups  in  the  assembly  halls  where  she  has 
a  lantern  and  stereopticon  views.  These  talks  are  very  short  and 
simple,  suited  to  the  age  and  character  of  her  listeners.  The  aim  is 
to  give  an  elementary  working  knowledge  of  tuberculosis  and  how  to 
combat  it.     Illustrations  are  used,  exhibits  are  set  up  in  the  schools, 


EDUCATIONAL  VALUE  OF  THE  NURSE  39 

and  attractive  illustrated  circulars  are  distributed  afterward,  with 
instruction  that  the  children  are  to  take  them  home  and  explain  them 
to  their  parents  and  friends.  Sometimes  they  write  essays  on  the 
subject,  and  their  work  shows  a  remarkably  clear  understanding  of  the 
main  points  involved.1  Dr.  John  M.  Withrow,  superintendent  of  the 
Cincinnati  League,  writes: 

I  cannot  speak  too  heartily  in  favor  of  education  in  the  schools  as  a  means 
of  promoting  our  work.  We  have  found  it  here  to  be  one  of  the  especially 
effective  and  popular  features  of  our  work.  I  am  inclined  to  think  that  it  is 
the  best  means  of  reaching  into  the  home. 

Dr.  White  of  Pittsburgh,  speaking  at  the  Sixth  International  Con- 
gress on  Tuberculosis  in  Washington,  1908,  says:2 

I  wish  to  call  especially  to  your  attention  the  educational  work  in  the 
schools.  No  one  can  do  municipal  work  without  being  convinced  that  it 
cannot  be  done  without  a  trained  nurse,  but  her  duty  is  that  of  an  educator, 
and  there  is  no  one  who  can  enter  the  home  as  readily  as  the  nurse  can  do, 
and  as  a  woman  can  do.  We  must  take  the  impressionable  age,  and  that  is 
childhood.  You  must  accomplish  results  by  repetition;  results  will  come 
in  time.  Remember  that  unless  we  have  systematic  efforts  in  education 
they  will  not  be  of  much  value.  We  must  continue  year  after  year  to  do  this 
work  if  we  are  to  obtain  results. 

In  both  these  cities  the  nurse  gives  talks  to  mothers,  to  working 
girls'  clubs,  Young  Women's  Christian  Associations,  and  other  groups 
of  women.  In  Cincinnati  the  school  instructress,  as  she  is  called, 
addresses  also  the  pupils  in  the  parochial  schools,  and  the  priests  have 
invited  her  to  talk  to  the  Sunday-school  children  on  Sunday  afternoons. 
But  the  talks  in  themselves  are  useless  unless  the  subject  is  made  con- 
crete and  practical.  Almost  none  of  them,  children  or  parents,  grasp 
the  significance  of  what  they  see  and  hear,  except  as  it  is  interpreted 
to  them  and  related  to  their  lives.  If  such  work  as  this  could  be  made 
a  feature  of  public-school  instruction  throughout  the  country,  we  might 
reasonably  expect  a  marked  fall  in  the  death  rate,  not  only  from  tuber- 
culosis but  from  other  preventable  diseases.  Results  are  seen  already 
in  increased  attendance  at  clinics,  more  intelligent  treatment  of  the 
sick,  and  more  sanitary  conditions  in  the  schools  and  homes.     This  is 

1  Bertha  L.  Stark,  "Anti-Tuberculosis  Work  in  the  Pittsburgh  Public  Schools," 
Report  of  the  Sixth  International  Congress  on  Tuberculosis,  III. 

2  Ibid.,  583. 


40  THE  NINTH  YEARBOOK 

only  one  phase  of  the  general  campaign  of  education  in  the  homes, 
dispensaries,  hospitals,  sanitariums,  and  everywhere.  The  moving- 
picture  show  is  the  latest  addition  to  the  teaching  forces,  and  will  doubt- 
less help  much  in  interesting  the  children.  This  school  work  has  been 
taken  up  in  Columbus,  Cleveland,  Philadelphia,  Hamilton,  Ontario, 
Hartford,  Connecticut,  Salem,  Massachusetts,  and  Washington,  D.C., 
on  the  same  plan,  and  many  other  cities  have  written  asking  for  infor- 
mation and  copies  of  the  literature  distributed.  Inquiries  have  been 
received  from  Russia  and  other  foreign  countries.1 

I  quote  Dr.  Darlington  again  in  regard  to  the  need  for  this  teaching 
and  the  peculiar  function  of  the  visiting  nurse : 

In  all  large  communities,  the  poorer  element  of  the  foreign-born  popula- 
tion presents  the  greatest  problem  encountered  in  municipal  health  work. 
Diversified  in  their  habits,  often  superstitious  and  resentful  of  any  inter- 
ference with  their  mode  of  life,  oppressed  by  poverty,  frequently  ignorant  or 
neglectful  of  the  simplest  sanitary  requirements,  their  assimilation  as  citizens 
of  their  adopted  country  comes  only  as  a  result  of  education — persistent, 
inclusive,  and  never-ending. 

In  public-health  work  this  education  is  brought  about  by  various  means. 
Lectures,  printed  instructions  and  publicity  in  all  its  forms  are  used,  but  the 
most  valuable  and  effective  form  is  found  in  individual  instruction  in  the 
home.  Personal  efforts,  advice,  instruction,  and  demonstration  offer  the 
most  practical  and  effective  means,  and  we  have  found  the  employment  of 
trained  nurses  for  this  purpose  of  inestimable  value. 

Dr.  Livingston  Farrand,  secretary  of  the  National  Society  for  the 
Prevention  of  Tuberculosis,  in  a  recent  lecture  at  Teachers  College, 
said  that  after  all  the  forces  of  prevention  and  cure  have  been  set  in 
operation — exhibits,  lectures,  sanitaria,  preventoria,  dispensaries,  etc. — 
he  believed  that  the  most  important  work  of  all  would  still  be  the  actual 
teaching  and  treatment  of  the  cases  in  the  homes  by  visiting  nurses. 

Dr.  Osier  never  loses  an  opportunity  of  magnifying  the  nurse's 
office: 

The  district  nurse  is  a  ministering  angel  everywhere.  If  I  were  not  a 
man,  I  would  rather  than  anything  else  be  a  district  nurse.  The  work  they 
do  in  connection  with  tuberculosis  is  of  the  greatest  value — visiting  the  patients, 
watching  over  them,  advising  them,  teaching  them  how  to  lead  rational 
lives. 

1  The  Tuberculosis  League  of  Pittsburgh  (published  monthly). 


EDUCATIONAL  VALUE  OF  THE  NURSE  41 

Dr.  Edward  Trudeau,  of  Saranac,  the  great  apostle  of  the  movement 
in  America,  says: 

In  regard  to  my  opinion  of  the  value  of  the  district  or  dispensary  nurse 
in  the  combat  with  tuberculosis,  I  have  always  felt  that  the  nurse's  visit  to 
the  house  and  her  personal  contact  with  the  people  were  essential  to  any  degree 

of  success  in  diminishing   infection  in  the  home People  who  won't 

go  to  lectures,  won't  read  and  won't  do  anything  they  hear  from  their  asso- 
ciates they  ought  to  do,  will  gather  around  a  nurse  in  their  own  homes  and 
appreciate  at  once  how  simple  are  the  measures  necessary  for  their  protec- 
tion. I  think  the  nurse  a  most  indispensable  weapon  in  the  great  warfare 
and  that  she  perhaps  accomplishes  more  in  practical  prevention  than  any 
other  agency. 

INFANT   MORTALITY 

It  is  the  same  story  with  infant  mortality.  Both  of  these  great 
destroyers  of  life,  tuberculosis  and  the  diseases  of  infancy,  affect  the 
school  in  a  very  vital  way.  Sir  James  Crichton-Browne  makes  the 
statement  that: 

Of  all  infants  born  in  our  large  towns,  some  20  or  30  per  cent  are  visibly 
damaged  at  the  time  of  birth,  and  of  the  70  per  cent  or  80  per  cent  that  pass 
muster  then,  some  probably  bear  in  their  nervous  systems  hidden  marks  of 
maternal  privation  that  will  come  to  the  surface  by  and  by.1 

It  seems  more  and  more  evident  that  if  the  race  is  to  be  radically 
improved,  it  is  necessary  to  begin  before  school  age,  indeed  before  birth 
in  the  education  and  care  of  the  mother,  and  later  in  the  protection  of 
the  child.  Physicians,  philanthropists  and  educationalists,  domestic- 
science  experts  and  vital  statisticians  are  all  working  toward  the  solution 
of  this  big  problem.  Dr.  J.  H.  M.  Knox,  assistant  in  pediatrics  at  the 
Johns  Hopkins  Hospital,  voices  the  opinion  of  many  experts  when  he 
says: 

There  is  no  person  in  the  community  who  can  be  of  equal  assistance  in 
the  prevention  and  cure  of  diseases  among  infants,  to  the  trained  nurse. 
....  From  considerable  experience  in  milk -station  work,  I  am  glad  to 
acknowledge  that  fully  one-half  of  the  benefits  from  the  distribution  of  pure 
milk  to  babies,  comes  directly  or  indirectly  through  the  instruction  and 
friendly  visiting  of  nurses.2 

In  the  recent  Conference  of  the  American  Association  for  the  Study 
and  Prevention  of  Infant  Mortality,  practically  every  paper  emphasizes 

1  Report  of  International  Congress  of  School  Hygiene,  96. 

2  Visiting  Nurses'  Quarterly  (Cleveland,  July,  1910). 


42  THE  NINTH  YEARBOOK 

the  absolute  necessity  of  the  nurse's  teaching  in  any  adequate  campaign 
against  infant  mortality. 

In  summer,  the  school  nurses  employed  by  the  Board  of  Health  in 
New  York  are  distributed  through  the  various  districts  of  the  city, 
co-operating  with  the  nurses  of  several  other  organizations  in  teach- 
ing the  mothers  and  caring  for  the  health  of  babies.  They  visit  each 
child  whose  birth  has  been  reported  by  a  midwife,  inquire  into  condi- 
tions, especially  in  reference  to  eye-infections,  and  instruct  the  mother 
in  the  care  of  the  baby,  including  hygiene,  feeding,  clothing,  bathing, 
and  the  value  of  fresh  air.  Repeated  visits  are  made  to  see  that  these 
instructions  are  followed.  When  it  is  considered  that  over  45  per  cent 
of  the  births  in  New  York  City  are  attended  by  midwives,  usually  of 
the  most  ignorant  type,  the  magnitude  of  the  work  will  be  realized. 
Dr.  Darlington  reports: 

The  midwives  soon  learned  that  the  nurses  were  visiting  their  cases,  and 
manifested  great  interest.  They  informed  the  mother  that  the  nurse  would 
call,  and  that  her  instructions  must  be  carefully  obeyed;  they  sought  instruc- 
tion for  themselves  and  followed  the  methods  advised,  and  the  reports  of 
improved  asepsis  and  better  care  on  their  part  can  be  counted  as  not  the 
least  of  the  results  of  the  nurse's  work. 

This  year  the  nurses  have  made  a  total  of  106,772  visits,  770  sick  babies 
have  been  treated  by  the  Department  of  Medical  Inspection,  with  a  total  of 
1,850  visits.  4,888  cases  have  been  referred  to  other  agencies  of  the  Confer- 
ence for  aid  or  treatment. 

I  quote  from  a  personal  letter  from  Dr.  Josephine  Baker,  who  is 
the  head  of  the  Department  of  Child  Hygiene  under  the  Board  of 
Health,  and  who  has  direct  control  of  all  this  work. 

Nurses  are  assigned  to  various  recreation  centers,  milk  depots,  and  diet 
kitchens  throughout  the  city,  and  at  these  centers,  in  connection  with  the 
doctor  who  is  also  assigned  to  this  duty,  they  hold  clinics  for  the  instruction 
of  mothers.  This  work  is  carried  on  wholly  with  the  idea  of  prevention  of  the 
diseases  of  infancy,  particularly  the  gastro-intestinal  diseases.  If  sick  chil- 
dren are  found  they  are  cared  for  by  the  nurse  acting  under  instructions  of  a 
department  physician.  I  am  glad  of  the  opportunity  to  heartily  commend 
the  work  of  the  nurses  in  this  department.  I  consider  it  a  most  valuable 
feature  of  the  work  the  department  has  done  in  preventive  medicine,  and 
that  it  opens  a  large  field  for  the  trained  nurse.  During  the  past  summer, 
including  the  months  of  June,  July,  August,  and  September,  3,383  children 
under  two  years  of  age  died  from  diarrhoeal  diseases.     During  the  summer 


EDUCATIONAL  VALUE  OF  THE  NURSE  43 

of  1908,  the  same  months,  4,180  children  died.  This  reduction  is  undoubtedly 
due  in  a  large  part  to  the  campaign  of  education  which  has  been  carried  on  so 
persistently  during  the  past  year. 

In  Philadelphia  results  showed  36  per  cent  less  infant  mortality  in 
the  districts  covered  by  the  municipal  nurses  than  in  the  rest  of  the  city 
as  compared  with  the  preceding  year,  notwithstanding  that  the  summer 
was  the  most  trying  one  in  thirteen  years.1 

The  plan  for  "little  mothers'"  classes  in  the  schools  of  New  York 
was  an  extension  of  the  work  for  the  prevention  of  infant  mortality. 
The  classes  are  started  in  early  summer  and  are  continued  through  the 
holidays.  The  older  girls,  and  sometimes  the  boys,  who  are  in  charge 
of  babies  at  home,  join  the  "little  mothers'"  clubs,  and  there  is  con- 
siderable competition  among  them,  for  as  yet  there  is  a  restricted  mem- 
bership. A  girl  who  is  not  so  fortunate  as  to  possess  a  baby  adopts  her 
neighbor's  so  she  may  qualify  for  membership.  Talks  are  given  by 
the  doctor  or  nurse  and  a  real  live  baby  is  secured  if  possible  for  the 
demonstrations.  The  children  show  the  greatest  enthusiam  over  the 
bathing  and  feeding  and  caring  for  the  baby,  and  carry  out  their  instruc- 
tions very  faithfully,  often  in  the  face  of  much  good-natured  protesta- 
tions from  their  mothers  and  the  neighbors.  But  the  foreign  peoples 
have  great  respect  for  the  wisdom  of  the  public  school,  and  where  the 
"little  mothers"  are  taking  command,  pickles  and  sauerkraut  are  dis- 
appearing very  gradually  from  the  baby's  rations  and,  at  the  first  sign 
of  illness,  it  is  hurried  to  the  nearest  milk  station  or  dispensary  for 
expert  advice. 

It  is  significant  that  a  corps  of  school  nurses  should  have  been  so 
largely  identified  with  this  great  wrork  of  child-saving.  It  points  to 
an  extension  of  their  functions  which  wdll  enable  the  school  to  "begin 
early"  in  preparing  its  pupils  for  education.  There  is  some  indication 
that  the  cities  are  waking  up  to  the  economic  significance  of  this  move- 
ment. 

In  New  York  City  we  have  asked  for  and  hope  to  receive  an  appropriation 
sufficient  to  employ  a  staff  of  nurses  large  enough  to  continue  this  work  through- 
out the  year.  It  is  an  economic  truism  that  the  saving  of  life  and  the  preser- 
vation of  health  offers  greater  value  to  the  state  than  can  be  gained  in  any 
other  way.     Governments  must  conserve  the  health  of  the  babies  and  the 

1  Paper  by  Dr.  Joseph  S.  Neff  at  the  Conference  of  Infant  Mortality  in  Balti- 
more, 1 9 10. 


44  THE  NINTH  YEARBOOK 

children  if  they  are  looking  to  the  future  and  virility  of  their  citizens,  and 
money,  time,  and  effort  can  be  expended  in  no  more  worthy  purpose.1 

In  Boston,  where  medical  inspection  is  under  the  Board  of  Education, 
the  nurses  are  detailed  for  playground  work  during  the  summer.  Some- 
times they  take  parties  of  children  to  the  country  or  seashore,  and  in 
other  ways  look  after  their  physical  welfare.  In  every  city  they  co-op- 
erate with  the  visiting  nurses'  societies,  milk  stations,  summer  camps, 
and  other  social  organizations. 

THE   ECONOMIC   VALUE    OF   THE   VISITING   NURSE 

The  wide  possibilities  of  the  work  in  the  family  and  the  co-operation 
with  other  social  forces  is  indicated  in  an  extract  from  a  paper  on  "The 
Visiting  Nurse": 

I  ought  to  speak  too  of  the  great  indirect  benefit  to  the  community  of  a 
visiting  nurse  who  is  alert  to  render  all  possible  services.  As  she  comes  to 
know  a  family  well,  she  can  often  put  her  finger  on  just  the  economic  or 
sanitary  shortcoming  of  that  family  which  keeps  them  poor  or  makes  them 
sick.  She  is  able  to  point  out  the  folly  of  the  cut-throat  chattel  mortgage; 
the  grocery  credit-book;  the  unnecessary  furniture  purchased  so  dearly  on 
the  alluring  instalment  plan;  the  ruinous  economy  of  living  in  dark  rooms  or 
amid  insanitary  surroundings  because  "the  rent  is  so  cheap";  the  suicidal 
policy  of  taking  the  children  prematurely  out  of  school  to  put  them  to  work. 

She  reports  to  the  charities  organization  headquarters  cases  of  destitution 
or  of  lack  of  employment,  ....  violations  of  sanitary  regulations,  and 
violations  of  the  child-labor  law.2 

Again  Miss  Wald  says: 

But  the  nurse  has  been  more  generally  accepted  as  the  conveyor  of  edu- 
cation to  the  individual,  the  interpreter  of  the  movement  to  the  people,  the 
guardian  of  the  parents  and,  indirectly  through  her  supervision  of  them,  the 
policeman  for  the  community.  The  educational  value  of  the  technically 
trained  and  socially  aroused  nurse  is  of  great  importance,  but  her  best  social 
value  lies  not  primarily  in  her  office  as  a  carrier  of  education,  but  in  the  clear- 
ness and  force  with  which  she  makes  known  and  understood  the  patients' 
accompanying  disease  of  poverty.  Teaching  individual  hygiene,  impressing 
upon  the  poor  consumptive  the  last  word  of  science  upon  the  healing  value 
of  sunshine,  importance  of  limited  hours  of  labor,  good  food,  etc.,  would  many 
times  appear  to  be  cruelly  sardonic  were  it  not  for  the  confidence  that  she 

1  Dr.  Darlington,  Address  to  the  Woman's  Municipal  League,  January,  1910. 

2  Caroline  B.  Crane,  Charities  and  the  Commons  (April  7,  1906). 


ED  UCA  TIONA  L  VALUE  OF  THE  N  URSE  45 

(the  nurse)  is  playing  her  part  to  urge  on  the  regeneration  of  living,  housing, 
child-protective  and  wage  conditions.  No  one  sees  as  well  as  she — not  even 
the  physician — all  the  misery,  the  heroic  struggles,  the  ignorance  and  super- 
stition in  the  double  struggle  against  poverty  and  illness.  Her  force  must 
be  tested  by  her  clearness  in  making  these  conditions  known,  as  well  as  by 
her  intelligence  in  caring  for  her  patients  and  by  her  value  as  a  teacher.1 

A  very  interesting  demonstration  of  the  economic  value  of  the 
visiting  nurse's  services  has  been  given  during  the  past  two  years  in 
New  York.  The  Metropolitan  Life  Insurance  Company  has  been 
instituting  a  plan  of  working  men's  insurance  under  Mr.  Lee  Frankel, 
who  was  formerly  head  of  the  Hebrew  Charities.  Miss  Wald,  of  the 
Henry  Street  Nurses'  Settlement,  quickly  saw  the  possibilities  in  the 
weekly  visiting  of  the  insurance  companies'  collectors,  and  asked  for  the 
co-operation  of  the  company  in  reporting  cases  of  illness  found  in  these 
homes.  This  led  to  an  arrangement  between  the  company  and  the 
settlement,  by  which  the  company  paid  at  the  rate  of  so  much  per  visit 
for  all  attendance  on  its  policy  holders.  A  very  complete  system  was 
arranged  and  the  results  carefully  tabulated  for  one  year.  They  were 
convinced  that  nursing  care  and  the  constant  instruction  of  the  visiting 
nurses  would  effect  a  decrease  in  the  morbidity  rate  and  enable  policy- 
holders to  get  to  work  sooner  and  keep  in  better  condition.  It  proved 
to  be  an  economic  gain  to  the  insurance  company  and  the  system  has 
already  been  established  in  a  great  many  other  cities.  Other  progres- 
sive organizations,  department  stores,  factories,  etc.,  engage  nurses 
not  so  much  to  care  for  sick  employees  as  to  look  after  their  comfort 
and  well-being,  to  tell  them  how  to  care  for  themselves  and  to  keep  them 
well.    This  is  not  a  philanthropy — it  is  a  business  proposition. 

IS  THIS  NURSING  WORK  ?      FLORENCE  NIGHTINGALE'S  CONCEPTION 

OF   NURSING 

It  has  been  noted  that  in  all  this  preventive  and  remedial  work  the 
services  of  the  nurse  as  teacher  and  social  worker  are  held  to  be  of  supreme 
importance.  She  has  been  so  closely  associated  in  the  public  mind  with 
the  actual  bedside  treatment  of  the  sick,  that  this  new  work  is  viewed  as 
something  of  an  anomaly.  But  Florence  Nightingale  saw  it  clearly 
from  the  first.     As  the  founder  of  trained  nursing  and  herself  the  great- 

1  Lillian  D.  Wald,  "Educational  Value  and  Social  Significance  of  the  Trained 
Nurse  in  the  Tuberculosis  Campaign,"  Report  of  Congress  on  Tuberculosis,  III,  632-38. 


46  THE  NINTH  YEARBOOK 

est  nurse — as  she  was  one  of  the  most  far-sighted  of  philanthropists, 
sanitarians,  and  social  economists  of  any  age — it  might  be  well  to  con- 
sider her  conception  of  "Nursing." 

The  very  elements  of  what  constitutes  good  nursing  are  as  little  understood 
for  the  well  as  for  the  sick.  The  same  laws  of  health  or  of  nursing,  for  they 
are  in  reality  the  same,  obtain  among  the  well  as  among  the  sick.  The  break- 
ing of  them  produces  only  less  violent  consequences  among  the  former  than 
among  the  latter,  and  this  sometimes,  not  always.1 

" Health-nursing "  she  calls  it  in  distinction  to  "sick-nursing." 
She  was  one  of  the  first  to  preach  the  gospel  of  fresh  air.  How  she  pleads 
for  the  lives  of  the  babies  in  the  close,  fetid  tenements  where  two  in  every 
five  die  before  they  are  five  years  old! 

The  life-duration  of  tender  babies  (as  some  Saturn  turned  analytical 
chemist  says)  is  the  most  delicate  test  of  sanitary  conditions.  And  Oh,  the 
crowded  national  school  where  so  many  children's  epidemics  have  their  origin, 
what  a  tale  an  air-test  would  tell!  We  should  have  parents  saying  rightly 
"I  will  not  send  my  children  to  that  school,  the  air- test  stands  at  'Horrid'  "! 

Again  she  says: 

We  have  tons  of  printed  knowledge  on  the  subject  of  hygiene  and  sanita- 
tion. The  causes  of  the  enormous  child-mortality  are  perfectly  well  known, 
but  how  much  of  the  knowledge  has  been  brought  into  the  homes  and  house- 
holds and  habits  of  the  people — poor  or  even  rich  ? 

She  speaks  in  fine  scorn  of  the  method  of  "sprinkling  lectures  over 
a  community  in  the  hope  of  teaching  public  health." 

The  chief  epidemic  that  reigns  this  year  is  "folly."  You  must  form 
public  opinion.  But  while  public  opinion  or  the  voice  of  the  people  is  some- 
what awake  to  the  building  and  drainage  question,  it  is  not  at  all  awake  to 

teaching  mothers  and  girls  practical  hygiene Is  it  better  to  learn 

the  pianoforte  than  to  learn  the  laws  which  subserve  the  preservation  of  off- 
spring ?  .  .  .  .    Where  then  is  the  remedy  for  this  ignorance  ? 

Everywhere  it  is  the  same  solution.  Education — the  people  must 
be  taught,  not  in  the  lecture-hall  but  in  the  home.  There  must  be  a 
corps  of  nurses  in  every  city  and  country  district — "missioners  of 
health,"  she  calls  them.  In  answer  to  the  contention  that  the  visiting 
method  is  slow,  she  says: 

What  is  slow  in  more  senses  than  one  is  the  eternal  lecturing,  words  that 
go  in  one  ear  and  out  the  other,  the  only  word  that  sticks  is  the  word  that  follows 

1  Florence  Nightingale,  Nursing,  What  It  Is  and  What  It  Is  Not. 


EDUCATIONAL  VALUE  OF  THE  NURSE  47 

work.     The  work  that  pays  is  the  work  of  the  skilful  hand,  directed  by  the 

cool  head,  and  improved   by  the   loving   heart The  point  is,  not 

"are  the  people  interested  in  the  lectures,"  but  did  they  practice  the  lecture 
in  their  homes  afterwards  ?  .  .  .  .  We  have  medical  officers,  immense  sanitary 
works;  we  have  not  nurses — missioners  of  health-at-home.1 

Most  of  this  was  written  between  i860  and  1870  and  the  same 
points  were  repeated  again  and  again  in  her  voluminous  writings.  She 
was  one  of  the  first  to  advocate  prevention,  and  it  was  due  to  her  that 
many  wide-reaching  sanitary  reforms  were  established  in  military 
camps,  in  cities,  in  rural  districts,  not  only  in  England  but  in  India  and 
everywhere.  And  it  was  women,  trained  women  always,  that  she 
appealed  to,  to  take  up  this  tremendous  teaching-task,  nurses  or  sani- 
tary inspectors  of  the  highest  character,  of  education  and  culture  to 
meet  a  need  "as  old  as  the  world,  as  large  as  the  world  and  as  pressing 
as  life  and  death." 

THE   FUTURE   DEVELOPMENTS   IN   SCHOOL-NURSING 

But  to  return  to  the  school  nurse.  The  tendency  at  present  seems 
to  be  toward  a  multiplication  rather  than  a  reduction  of  her  functions. 
Some  advise  a  rigid  restriction  of  her  duties  to  routine  inspection  of  the 
most  superficial  sort,  which  means  that  she  is  to  detect  vermin  and  dirt 
and  other  extremely  obvious  and  unpleasant  things,  but  must  carefully 
avoid  any  meddling  with  physical  defects,  and  must  on  no  account 
presume  to  exclude  on  her  own  authority  a  case  of  infectious  disease. 
On  the  other  hand,  the  hard-pressed  medical  inspectors  are  themselves 
asking  that  she  should  not  only  examine  the  eyes,  throats,  etc.,  of  the 
children  daily  or  at  least  weekly,  but  that  she  should  assist  also  in  making 
measurements,  testing  vision  and  hearing,  and  should  in  every  way 
help  the  physician  to  do  his  work  economically  and  efficiently.  Dr. 
Cabot,  of  Boston,  has  pointed  out  that  the  training  in  observation  which 
the  nurse  has,  and  her  experience  in  the  schools,  enable  her  to  discover 
even  more  quickly  than  the  young  doctor  the  first  symptoms  of  the 
infectious  disease.     He  states: 

For  ten  years  in  Boston  schools  the  average  number  of  cases  of  scarlet 
fever  found  each  year  under  inspection  of  teachers  and  doctors  was  14.  In 
1908  under  inspection  of  school  nurses,  1,000  cases  were  found.  That  means 
that  the  nurses  were  nearly  seventy  times  as  good  as  the  teachers  in  making 

1  Nutting  and  Dock,  History  of  Nursing,  II,  chap.  v. 


48  THE  NINTH  YEARBOOK 

the  diagnosis  of  scarlet  fever  under  so-called  medical  inspection  (really  teach- 
ers' inspection).  The  average  number  found  each  year  was  86  cases  of 
measles.  The  school  nurses  in  1908  found  2,285  cases,  or  about  thirty  times 
as  many.1 

It  is  obvious  that,  for  many  years  to  come,  the  number  of  children 
under  the  care  of  one  school  doctor  will  be  much  too  large  for  any  care- 
ful and  systematic  inspection.  With  the  co-operation  of  an  adequate 
nursing  staff,  the  work  could  be  divided  so  that  the  physician's  time 
could  be  saved  for  actual  examination  and  diagnosis.  I  need  not  say 
that  the  salaries  offered  in  most  of  our  American  systems,  do  not  in- 
duce the  best  type  of  medical  man  to  go  in  for  medical  inspection,  or 
to  stay  at  it  till  they  become  proficient.  A  few  trained  experts  with  a 
good  staff  of  nurses  will  do  much  better  work  than  a  large  staff  of 
young,  untrained  physicians. 

Hogarth  points  to  the  extension  of  the  school  nurse's  duties  in  sev- 
eral different  ways — the  possibility  of  gradually  replacing  school- 
attendance  officers  by  school  nurses,  the  need  of  special  work  in  con- 
nection with  infants  and  nursery  schools,  the  systematic  treatment  of 
chronic  diseases  in  regularly  organized  and  equipped  school  clinics, 
and  the  increasing  development  of  fresh-air  and  special  schools  for 
defective  and  debilitated  children,  where  a  resident  nurse  would  always 
be  needed. 

In  any  case  the  school  nurse  is  definitely  an  education  officer  and  not 
merely  a  district  nurse  or  health  visitor  employed  by  the  schools.  Her  first 
instinct  and  duty  must  be  to  promote  the  efficiency  of  school  routine  by 
increasing  attendance  and  improving  the  health  of  the  children.  At  the 
same  time  her  work  should  be  directed  toward  the  education  of  the  children 
in  the  principles  of  cleanliness  and  of  healthy  living.  She  should  be  inter- 
ested in  the  simpler  problems  of  school  hygiene  and  should  call  the  attention 
of  the  teachers  and  children  to  the  necessity  of  open  windows,  to  the  harm- 
fulness  of  wet  clothes  and  boots  and  to  other  similar  matters.  Incidentally 
she  should  take  notice  of  all  sickly  and  ailing  children  and  should  endeavor, 
when  necessary,  to  get  medical  assistance.  Sometimes  she  may  be  able  to 
obtain  the  help  of  voluntary  societies  for  the  purpose  of  sending  a  child  to  the 
hospital  or  into  the  country.  By  these  and  similar  methods  she  may  hope 
to  train  the  parents,  through  their  children,  to  aim  at  a  higher  standard  of 
health  and  comfort  in  the  homes.2 

1  Ninth  Yearbook,  Part  I,  "Health  and  Education." 

2  Medical  Inspection  in  Schools,  chap,  xii,  180-81. 


EDUCATIONAL  VALUE  OF  THE  NURSE  49 

Of  course  in  the  question  of  clinics,  there  would  have  to  be  special- 
ization, for  no  one  nurse  could  possibly  cover  all  phases  of  the  work 
even  in  one  large  school.  Miss  Margaret  MacMillan,  of  Bradford,  Eng- 
land, who  has  written  and  done  so  much  for  school  children,  has  recently 
instituted  a  school  clinic  in  Bradford,  where  one  nurse  treats  as  many 
as  sixty  cases  in  an  afternoon. 

There  is  another  field  of  school  hygiene  which  will  inevitably  fall 
to  the  nurse's  province,  a  type  of  work  in  which  her  hospital  experience 
ought  to  make  her  pre-eminently  successful.  That  is  the  routine  sani- 
tary inspection  of  school  buildings.  In  a  report  made  before  an  incor- 
porated society  of  medical  officers  of  health,  in  November,  1902,  Dr. 
Bruce  offers  this  as  one  of  many  recommendations  for  a  system  of 
administrative  hygiene  in  Scottish  schools: 

As  regards  ordinary  sanitary  arrangements,  such  as  cleanliness  of  the 
school-rooms,  the  clothes  of  the  scholars,  proper  airing  and  heating  of  the 
classrooms,  sweetness  of  the  latrines,  and  general  tidiness  of  the  school  and 
its  appurtenances,  we  believe  that  such  matters  would  be  best  dealt  with 
by  a  staff  of  female  inspectors.1 

Of  course  in  Britain  there  are  specially  trained  women  for  just  such 
work.  Mr.  Lawrence  Veiller,  who  has  done  such  remarkable  service 
as  head  of  the  Tenement  House  Commission  in  New  York  City,  pays 
the  highest  tribute  to  the  worth  of  women  sanitary  inspectors  as  com- 
pared with  the  average  man  inspector  in  his  department,  and  particu- 
larly to  those  who  had  the  training  as  nurses.  If  hospital  ideals  of 
cleanliness  and  disinfection  could  be  applied  to  public-school  buildings, 
there  would  be  a  marked  improvement  in  the  health  of  the  children  and 
teachers  from  this  cause  alone. 

The  question  of  authority  might  be  a  difficult  one  here — whether 
such  an  inspector  would  have  power  to  enforce  her  demands,  and  who 
should  back  her  up,  the  board  of  education,  the  board  of  health,  the 
school  physician,  or  the  school  principal.  Under  one  expert  health 
authority  in  a  large  system,  there  would  be  little  difficulty,  but  in  a 
small  system  her  duties  and  powers  would  have  to  be  plainly  defined. 

The  value  of  home  visiting  has  already  been  sufficiently  emphasized. 
It  would  seem  that  this  work  ought  to  be  extended  to  include  a  more  or 
less  regular  visiting  of  the  homes  of  all  the  children.     In  many  instances 

1  MacKenzie  and  Matthews,  Medical  Inspection  of  School  Children,  123. 


50  THE  NINTH  YEARBOOK 

it  is  only  the  children  who  are  fortunate  enough  to  be  "cases"  who 
receive  any  special  attention  at  all.  Probably  the  greatest  number  of 
the  homes  present  the  same  needs  as  do  these  that  are  visited,  but  con- 
ditions never  come  to  light,  and  parents  and  child  and  school  and  com- 
munity are  all  the  losers.  The  nurse  could  be  that  much-needed  link 
between  the  home  and  the  school,  interpreting  the  ideals  and  purposes 
of  the  school  to  the  home,  and  discovering  the  limitations  and  adverse 
conditions  which  surround  the  children  there — conditions  which  so 
vitally  affect  the  best  efforts  of  the  school.  As  a  nurse  she  finds  out 
quite  incidentally  many  facts  that  a  social  investigator  would  find  it 
hard  to  secure.  The  experience  of  school  nurses  and  of  district  nurses 
is  that  the  mothers  welcome  the  opportunity  of  talking  over  many 
troublesome  problems  that  would  never  be  discussed  with  the  ordinary 
visitor.  This  is  simply  because  of  the  nurse's  training  and  experience, 
and  it  is  as  noticeable  in  the  homes  of  the  well-to-do  as  among  the  poorer 
people. 

There  is  moreover  a  well-organized  popular  sentiment  in  favor  of 
the  visiting  nurse  which  gives  her  special  advantage  as  a  social  visitor. 
Even  without  the  bonnet  and  cloak  which  has  become  so  familiar  and 
safe  a  badge  in  the  lowest  slums  of  the  older  cities,  the  "lady  with  the 
bag"  is  not  only  tolerated  but  welcome  in  the  homes  of  the  most  igno- 
rant and  degraded.  The  visiting  nurse  has  won  her  way,  not  without 
difficulty  even  here  in  America;  but  wherever  her  work  is  known,  her 
position  is  assured.  Even  the  new-come  foreigners,  at  first  so  sus- 
picious, early  learn  to  know  and  trust  her.  Hers  is  a  service  that  they 
can  understand ;  she  makes  them  comfortable ;  she  eases  their  pain ;  she 
sees  that  their  urgent  needs  are  supplied.  The  school  nurse  builds  on 
the  work  which  these  early  nursing  pioneers  have  done,  and  inherits 
the  good  graces  and  the  confidence  of  the  people.  It  would  take  a  long 
time  for  any  new  type  of  social  visitor  to  win  such  a  place. 

In  regard  to  the  teaching  of  hygiene,  there  will  always  be  a  difference 
of  opinion  as  to  how  the  subject  is  to  be  taught,  and  who  is  to  do  the 
teaching.  It  matters  very  little  which  type  of  specialist  is  engaged  to 
do  the  work,  for  after  all  success  depends  on  the  individuality  of  the 
teacher  and  on  his  or  her  enthusiasm,  rather  than  on  special  academic 
preparation.  Responsibility  will  be  divided  according  to  the  number 
of  special  teachers  and  officials  available  and  their  relative  qualifications, 
and  according  to  local  needs;   sometimes  it  will  be  the  regular  grade 


EDUCATIONAL  VALUE  OF  THE  NURSE  5 1 

teacher,  sometimes  a  biology  or  physical-education  or  domestic-science 
teacher,  sometimes  a  doctor  or  nurse. 

I  have  attempted  to  show  that  the  strength  of  the  nurse's  teaching 
lies  in  the  practical  application  of  simple  principles  to  everyday  con- 
crete situations.  This  is  not  such  a  new  type  of  teaching  as  it  was  in 
the  time  of  which  Florence  Nightingale  wrote,  or  the  earlier  days  of 
school  nursing.  Honnor  Morten  speaks  of  the  teaching  in  the  London 
schools: 

The  poor  children  are  being  "  told"  things  all  day  long.  The  nurse  showed 
them,  and  because  she  was  not  regarded  as  a  teacher,  was  the  best  instructor 
in  the  most  important  and  most  neglected  branch  of  education. 

The  matter  of  sex-hygiene  is  difficult  because  there  are  so  many 
factors  to  be  considered  in  any  proposal  for  the  teaching  of  the  subject 
in  the  schools.  It  is  apparent  however  that  the  nurse  more  than  any 
other  social  worker,  except  perhaps  the  doctor,  sees  the  dreadful  havoc 
that  ignorance  makes  in  human  lives.  That  whole  dark  seamy  side 
of  life  which  is  laid  bare  in  the  hospital  wards  cannot  fail  to  impress 
any  thoughtful  person  with  the  necessity  of  full  and  adequate  knowledge 
for  the  self-protection  of  all  young  people,  and  especially  of  girls. 
Whether  such  knowledge  can  be  given  in  the  form  of  class  instruction 
or  not,  it  would  seem  that  a  wise  and  tactful  nurse  who  is  associating 
freely  with  the  children  could  give  much  personal  advice  and  assistance 
to  the  older  girls  in  the  school,  at  the  same  time  supervising  their  health 
and  watching  over  their  development. 

Experiences  in  girls'  clubs  in  the  settlements  has  shown  that  they 
do  appreciate  such  instruction  and  often  ask  for  it.  They  consult  a 
nurse  more  readily  because  they  know  that  this  is  such  an  everyday 
subject  with  her.  Any  teacher  who  can  discuss  such  questions  natu- 
rally and  without  self-consciousness  helps  the  girls  to  take  a  sane  and 
healthier  view  of  the  subject,  and  if  the  doctor  or  the  nurse  can  do  this 
without  introducing  the  pathological  element  unduly,  much  good  should 
result. 

But  whatever  may  be  the  difficulties  here,  there  can  be  no  doubt 
that  every  pupil  ought  to  have  some  instruction  on  the  subject  of  home 
nursing  and  first  aid  in  emergencies.  Some  little  work  of  this  kind 
is  being  done  in  connection  with  some  courses  in  domestic  science, 
but,  especially  in  the  eighth  grade  and  in  the  high  school,  it  deserves 


52  THE  NINTH  YEARBOOK 

a  much  larger  place  in  the  girl's  training.  The  subject  should  be  taught 
by  a  well-qualified  trained  nurse,  and  should  consist  largely  of  demon- 
strations and  practical  work.  It  is  an  excellent  medium  for  driving 
in  the  vital  facts  of  hygiene  and  sanitation  and  developing  the  finer 
instincts  of  growing  girls.  The  care  and  feeding  of  children  comes  in 
incidentally  with  such  a  course,  and  the  "little  mothers' "  classes  show 
with  what  a  splendid  enthusiasm  and  practical  skill  the  girls  apply  the 
principles  taught.  The  same  kind  of  work  is  being  done  with  excellent 
results  in  "grown-up"  mothers'  clubs  and  evening  classes  for  young 
women. 

With  such  an  accumulation  of  needed  duties,  it  would  require  the 
service  of  one  nurse  for  each  of  our  large  schools,  and  this  will  probably 
be  the  ultimate  solution  of  some  of  these  vexed  problems.  Miss  Mar- 
garet MacMillan,  in  a  recent  address  under  the  auspices  of  the  Public 
Education  Association  of  New  York,  gave  as  her  opinion  that,  as  soon 
as  the  urgent  need  for  treatment  and  nursing  care  diminishes  as  it  must 
do  in  the  schools,  the  nurse  will  be  employed  more  and  more  in  these 
other  fields,  but  so  far  the  number  of  nurses  is  so  inadequate  that  their 
services  should  be  available  for  those  dutues  which  seem  most  pressing. 

ORGANIZATION  AND  ADMINISTRATION   OF   SCHOOL  NURSING 

We  come  now  to  the  question  of  organization  and  administration. 
As  has  been  noted,  the  work  exists  under  a  variety  of  managements — 
private  charity,  visiting  nurses'  societies,  boards  of  health,  and  boards 
of  education.  There  seem  to  be  special  advantages  and  disadvantages 
about  each  form  of  organization.  Where  the  work  is  under  the  visiting 
nurses'  societies,  the  school  nurses  are  appointed  from  the  regular  staff, 
and  have  usually  the  advantage  of  a  wide  social  experience.  They 
know  the  city  and  the  homes,  are  acquainted  with  all  the  charitable 
organizations,  the  courts,  and  the  boards  of  health,  etc.  In  this  way 
a  much  closer  co-operation  with  other  social  forces  is  possible.  The 
board  of  education  has  no  responsibility  for  details  of  organization  and 
simply  pays  the  salaries  of  the  nurses.  In  Cleveland  where  the  work 
is  under  the  Visiting  Nurses'  Society,  the  nurses  are  employed  as  teach- 
ers and  have  been  placed  on  the  teachers'  schedule,  the  amount  received 
being  based  on  experience  and  efficiency.  Such  a  plan  has  worked  very 
well  in  that  city  and  in  many  others  and  is  to  be  recommended  for  all 
smaller  cities  where  there  is  an  efficient  district-nursing  organization. 


EDUCATIONAL  VALUE  OF  THE  NURSE  53 

One  great  advantage  of  this  arrangement  is  that  the  appointment  of 
the  school  nurse  is  made  by  a  nursing  body  which  not  only  investi- 
gates her  credentials  but  tries  out  the  applicant  in  the  field  of  district 
nursing.  Many  of  those  who  apply  depend  on  political  pull  to  get  in. 
They  may  have  no  aptitude  for  the  work,  not  even  a  proper  hospital 
training,  and  frankly  desire  to  get  into  school  work  because  of  the 
short  hours  and  easier  duties.  Rural-school  nursing  could  be  started 
in  the  same  way  as  in  Great  Britain,  but  unfortunately  rural  district 
nursing  is  not  at  all  well  developed  in  America. 

As  to  whether  the  board  of  health  or  the  board  of  education  should 
be  in  control  of  the  situation  in  the  larger  cities,  there  seems  to  be  no 
uniformity  of  opinion.  As  far  as  the  nursing  in  its  present  scope  is 
concerned,  there  is  probably  little  difference.  Should  the  nurse's 
duties  be  extended,  however,  and  especially  should  she  be  engaged  for 
any  teaching  duties,  it  would  seem  more  fitting  that  she  should  be  in 
closer  touch  with  the  educational  organization. 

Dr.  Osier  says: 

The  ideal  conditions  are  easily  defined.  First,  a  central  department  at 
the  Board  of  Education  which  would  supervise  and  co-ordinate  work  through- 
out the  country;  secondly,  at  each  school  an  intelligent  woman,  preferably 
one  who  has  had  experience  as  a  nurse,  whose  duty  it  would  be  to  carry  out 
anthropometric  observations  at  stated  intervals,  to  assist  the  doctor  in  all 
matters  relating  to  the  hygiene  of  the  school  and  the  personal  hygiene  of  the 
children;  thirdly,  a  school  dentist  who  would  make  an  inspection  of  the 
mouths  of  the  children  and  put  their  teeth  in  order;  and  lastly,  the  school 
doctor.1 

When  a  regular  instructor  in  physical  education  is  employed,  meas- 
urement, weights,  etc.,  are  usually  under  that  department.  It  is 
important  that  there  should  be  the  greatest  harmony  and  co-operation 
between  these  different  specialists;  this  can  be  more  readily  effected 
where  all  health  functions  are  under  one  expert  head. 

In  his  recommendation  of  machinery  for  health  supervision  and 
instruction  in  the  schools  of  the  city,  Dr.  Allen  advises,  among  other 
features,  "a  staff  of  nurses  to  assist  medical  examiners  to  give  practical 
demonstrations  in  cleanliness,  to  teach  mothers  the  care  of  children, 
both  at  their  homes  and  in  mothers'  meetings,  to  enlist  the  co-operation 

1  "Medical  and  Hygienic  Inspection  of  Schools,"  Report  of  Second  International 
Congress  of  School  Hygiene,  468. 


54  THE  NINTH  YEARBOOK 

of  family  physicians  and  neighborhood  facilities  such  as  hospitals,  dis- 
pensaries and  relief  agents,  magistrates,  courts,  and  probation  officers, 
all  to  be  under  the  board  of  education  or  the  board  of  health."1  For 
the  county  he  would  have  "a  physician  and  nurse  to  organize  inspec- 
tion and  instruction  for  rural  schools,  to  give  lessons  and  make  demon- 
strations at  county  institutes,  to  show  teachers  how  to  interest  physi- 
cians, dentists,  health  officers,  and  parents  in  the  physical  welfare  of 
school  children."  The  hygiene  of  school  buildings  would  also  be  under 
their  inspection. 

In  regard  to  the  relative  number  of  doctors  and  nurses  required, 
there  is  the  greatest  difference  of  opinion.  Much  depends  on  the 
amount  of  time  which  the  school  doctor  devotes  to  his  work.  Often 
there  are  nurses  but  no  regular  physicians  employed,  and  here  of  course 
the  more  pronounced  cases  are  referred  to  home  physicians  or  dispen- 
saries for  diagnosis  and  treatment.  Sometimes  the  school  is  inspected 
daily,  sometimes  weekly  or  even  monthly.  The  nurse  may  have  1,000 
children  under  her  care  or  she  may  have  10,000.  Dr.  Newmayer  says 
one  nurse  is  capable  of  attending  to  five  schools  with  5,000  children, 
visiting  three  in  the  morning  and  two  in  the  afternoon,  and  doing 
the  home  visiting  after  school.  Usually  when  she  visits  the  school 
every  day,  she  has  time  to  treat  only  the  chronic  cases  and  those  which 
the  teacher  and  doctor  send  to  her,  leaving  the  routine  inspection  in 
the  classroom  to  be  done  as  she  can  find  time.  In  London  one  nurse 
might  have  from  24  to  48  schools  to  inspect. 

Only  in  the  event  of  gross  neglect  or  ignorance  on  the  part  of  the  parents 
are  the  nurses  required  to  follow  the  children 'to  their  homes  and  to  advise  the 
parents.  Their  original  powers  for  the  exclusion  of  verminous  children  were 
severely  restricted.  If  after  repeated  visits  the  children  are  still  unfit  to  asso- 
ciate with  others,  the  case  is  taken  up  with  the  divisional  superintendent 
who  summons  the  parents  to  the  police  court  to  explain  why  the  children  are 
not  in  school.  The  magistrate  usually  imposes  a  fine  which  is  heavier  for  a 
second  offense.2 

Of  the  routine  inspection  Dr.  Hayward  says : 

Often  as  many  as  200  or  250  children  pass  before  the  nurse  at  one  time. 
She  detains  them  merely  long  enough  to  glance  at  their  head,  skin,  eyes,  nose, 
and  general  appearance,  and  then  if  nothing  seems  wrong,  she  passes  them  on. 

1  Civics  and  Health,  292-94. 

2  Helen  L.  Pearce,  "The  Place  of  the  School  Nurse,"  British  Journal  of  Nursing 
(August  17,  1907). 


EDUCATIONAL  VALUE  OF  THE  NURSE  55 

In  these  superficial  examinations,  the  trained  school  nurse  becomes  an  ex- 
pert in  the  detection  of  evidences  of  skin  and  eye  diseases,  adenoids,  enlarged 
tonsils,  suspected  tuberculosis,  and  the  first  signs  of  various  children's  diseases. 
She  is  the  sieve  through  which  the  children  pass  before  being  brought  directly 
to  the  physician,  and  it  is  a  matter  of  great  importance  that  her  training  be 
thorough  and  her  observation  acute. 

The  work  is  carried  on  in  the  school  station  where  all  necessary  surgical 
supplies  and  utensils  are  kept,  and  the  nurse  gives  the  children  practical  in- 
struction in  bandaging,  dressings,  and  in  various  points  of  cleanliness  and 
personal  hygiene. 

In  Philadelphia  the  physician  and  nurse  visit  each  school  daily  at 
a  stated  time.  A  room  is  set  apart  in  each  school  for  their  use;  the 
pupils  are  sent  down  to  the  office  by  the  teachers  and  are  individually 
examined.  A  card  system  is  used  and  for  each  child  a  card  is  sent  to 
the  principal.  Records  are  kept  showing  the  date  of  treatment,  care, 
etc.  When  the  pupil  needs  treatment  and  no  physician  is  in  attend- 
ance at  home,  a  paper  is  signed  by  the  parent  asking  the  doctor  and 
nurse  to  take  care  of  the  case.  For  pediculosis,  cards  with  printed 
directions  for  treatment  are  sent  to  the  homes.  Every  day  the  nurse 
goes  through  one  or  more  classrooms,  observing  the  condition  of  each 
child.  This  is  done  with  no  interruption  of  classroom  work.  No  excuse 
for  non-treatment  is  accepted.  If  the  parents  are  too  poor  to  provide 
the  necessary  glasses,  and  the  nurse  has  ample  proof  of  such  a  condi- 
tion, she  devises  some  method  of  obtaining  the  glasses.  In  every  case, 
however,  the  parents  are  asked  to  pay  a  small  sum  toward  the  expense 
and,  by  giving  a  trifle  each  week,  this  can  usually  be  done.  The  idea 
is  to  make  the  parents  feel  their  responsibility  for  the  child's  health  and 
not  to  encourage  pauperization.  It  has  been  observed  that  the  effect 
of  home  visiting  is  to  awaken  interest  and  to  develop  the  feeling  of 
responsibility  in  the  parents,  rather  than  to  make  them  more  dependent 
on  outside  agencies. 

In  New  York  each  nurse  has  from  two  to  seven  schools  with  an 
average  of  4,000  children.  She  visits  the  schools  in  the  morning  usually, 
for  routine  treatments  and  special  cases.  As  little  interruption  as  pos- 
sible of  the  regular  school  work  is  incurred.  At  a  given  signal,  children 
whose  names  have  previously  been  sent  to  the  teachers  go  to  the  medi- 
cal room  to  see  the  inspector.  At  another  signal  those  who  are  to  go 
to  see  the  nurse  are  excused.     When  school  closes  at  3:00  p.m.,  the 


56  THE  NINTH  YEARBOOK 

nurse  makes  the  home  visits,  ten  being  considered  the  average  number 
for  each  day.  One  visit  does  not  always  bring  results;  sometimes  as 
many  as  five  visits  have  to  be  made  before  parents  realize  the  impor- 
tance of  medical  care. 

The  routine  inspection  consists  of  a  class  to  class  examination  which 
is  done  systematically  and  regularly.  The  children  pass  before  the 
nurse,  pulling  down  their  eyelids  as  they  pass,  the  condition  of  the 
hands  being  noted  at  the  same  time;  the  throat  and  hair  are  also  exam- 
ined. In  New  York  at  present  there  is  no  time  to  do  this  oftener  than 
about  once  a  month.     Miss  Rogers  says : 

The  number  of  children  which  one  nurse  can  properly  examine  each  week 
and  take  care  of  is  about  three  thousand.  Where  conditions  are  bad,  the 
routine  examination  should  be  made  every  week;  in  other  localities  every 
second  week  is  sufficient. 

The  doctor  and  the  nurse  do  not  always  visit  the  school  at  the  same 
time.  A  code  is  used  to  denote  the  principle  affections  from  which  the 
children  suffer.  If  there  are  any  cases  for  treatment,  the  doctor  leaves 
a  card  for  each  child  indicating  the  trouble  by  the  code  number.  In 
the  same  way  the  nurse  leaves  cards  showing  the  cases  which  ought  to 
be  referred  to  the  physician.  The  treatment  in  each  of  these  type 
cases  is  very  much  the  same.  When  children  are  to  be  treated  at  home, 
simple  and  explicit  directions  are  given  on  the  card. 

The  question  of  securing  adequate  attention  for  the  poor  child  is 
still  one  of  the  unsolved  problems.  In  Cincinnati  they  have  special 
dispensaries  for  school  children,  and  abroad  this  is  being  carried  out  more 
fully  than  in  America.  In  New  York  the  regular  dispensaries  in  the 
congested  districts  cannot  treat  all  the  children  who  are  brought  by  the 
nurses.  Miss  Rogers  hopes  to  see  school  dispensaries  established,  where 
the  children  can  be  sent  directly  from  school. 

The  hours  should  be  arranged  so  that  there  will  be  no  loss  of  school  time 
for  the  children  and  where  our  own  physicians  and  nurses  will  be  in  attendance. 
Every  one  then  connected  with  the  work  should  have  the  same  interest  and 
the  responsibility  could  not  be  shifted  from  one  division  to  another.1 

A  great  many  of  the  blank  forms  used  in  the  various  systems  of 
medical  inspection  will  be  found  in  Medical  Inspection  of  Schools,  by 

1  Lina  L.  Rogers,  "Some  Phases  of  School  Nursing,"  American  Journal  of  Nurs- 
ing (September,  1908);  also  ibid.  (January,  1907). 


EDUCATIONAL  VALUE  OF  THE  NURSE  57 

Gulick  and  Ayres,  and  in  Dr.  Newmayer's  System  Employed  by  the 
Trained  Nurses  in  the  Schools  of  Philadelphia. 

The  following  outfit  is  provided  for  the  medical  room  in  each  of  the 
New  York  schools.  I  may  say,  however,  that  the  equipment  is  often  of 
the  crudest  kind  and  quite  inadequate  in  view  of  modern  clinical 
requirements: 

i  screen  Boracic  acid  powder 

i  cabinet  Tr.  green  soap 

2  chairs  (i  high)  Collodion 

i  table  Vaseline 

i  scrap  basket  White  precipitate  ointment 

12  towels  2  basins  (white  granite) 

Absorbent  cotton  i  glass  jar  (i  gallon) 

Absorbent  gauze  i  ointment  jar  (glass) 

Bandages  Bichloride  mercury  tablets 

I  quote  further  from  Miss  Rogers : 

The  supervising  nurse  has  entire  charge  of  the  school  nurses  and  is  respon- 
sible for  the  efficiency  and  character  of  the  work  performed  by  each  nurse 
in  all  boroughs  of  the  city.  It  is  her  duty  to  make  arrangements  for  begin- 
ning work  in  the  schools  and  to  see  that  the  necessary  supplies  are  provided 
by  the  department  of  education.  She  also  regulates  the  proper  amount  of 
work  for  each  nurse,  making  whatever  changes  and  transfers  are  necessary, 
and  inspects  the  work  of  each. 

The  supervising  nurse  receives  all  the  reports,  which  she  examines 
and  corrects.  These  are  sent  in,  one  every  day,  one  every  ten  days, 
and  one  every  month.  The  supervisor  makes  a  general  summary  which 
is  forwarded  to  the  chief  inspector.  The  nurses  report  to  her  at  a 
weekly  meeting.  In  New  York  the  nurses  must  pass  the  civil-service 
examination  and  new  appointees  are  selected  from  the  list.  There 
has  been  much  difficulty  in  keeping  the  service  free  from  undesirable 
applicants,  but  standards  are  being  gradually  raised.  The  number 
of  hours'  work  given  by  the  nurse  vary  also,  the  extremes  being  from 
8:oo  a.m.  to  5:00  p.m.  in  one  city,  and  from  9:00  a.m.  to  3:30  p.m.  in 
another.  The  nurses  in  New  York  work  half-days  on  Saturday,  and 
during  summer  when  they  are  working  with  the  babies  they  take  turns 
on  Sundays  for  emergency  calls.  The  home  visits  nearly  always  require 
longer  than  the  stated  time,  and  nurses  find  themselves  often  as  late 
as  7:00  p.m.  before  they  are  through.  The  records  have  to  be  made 
up  at  night,  and  this  adds  to  the  work  considerably.     The  average 


58  THE  NINTH  YEARBOOK 

salary  is  $75  per  month,  though  it  ranges  all  the  way  from  $50  to  $100 
per  month.     Supervisors  get  from  $900  to  $1,200  per  year. 

Dr.  Frederick  Rose  at  the  International  Congress  of  Nurses  held 
in  London  in  July,  1909,1  dealt  with  the  significance  of  the  movement: 

Great  developments  may  be  expected  within  the  next  ten  years  from  the 
institution  of  school  medical  inspection.  It  will  soon  include  school  medical 
treatment  in  hospitals  or  school  clinics.  This  again  must  lead  to  some  form 
of  general  medical  inspection  before  school  age;  and  generally  speaking,  the 
question  of  the  home  conditions  of  school  children,  which  lies  at  the  root  of 
the  whole  matter,  will  receive  more  detailed  and  effective  consideration.  The 
whole  development  of  school  hygiene  is  pointing  in  the  direction  of  a  minis- 
try of  Public  Health,  the  municipalization  of  the  health  services  of  the  nation. 
In  a  few  years,  on  the  basis  of  one  doctor  and  two  nurses  to  every  2,000  chil- 
dren, about  4,000  doctors  and  8,000  nurses  may  be  necessary.  It  is  therefore 
obvious  that  the  occupation  of  the  school  nurse  is  one  of  the  coming  profes- 
sions for  women.  It  is  a  reasonable,  interesting,  and  important  profession, 
with  a  fixed  salary,  a  recognized  status,  regular  work,  and  a  suitable  amount 
of  leisure. 

Women  entering  this  profession  of  school  nurses  will  be  privileged  to  take 
part  in  one  of  the  most  far-reaching  and  important  developments  of  modern 
times.    It  is  beyond  reasonable  doubt  that  the  coming  of  school  hygiene  will 

gradually  effect  a  complete  change  in  our  views  on  education The 

development  of  school  nursing  will  assist  medical  science  in  the  accomplish- 
ment of  its  three  great  stages  of  progress — the  abandonment  of  the  first  or 
primitive  stage,  that  of  the  mere  detection  and  cure  of  disease — the  second 
stage,  that  of  the  prevention  of  disease — and  the  final  and  greatest  stage,  the 
raising  of  the  standard  of  vitality  of  the  whole  human  race. 

THE  PREPARATION  OF  THE  SCHOOL  NURSE 

It  is  evident  that  this  work  is  here  to  stay  and  it  is  probable  that 
it  will  be  extended  into  wider  and  wider  fields.  While  not  strictly 
nursing  in  the  accepted  sense,  it  requires  the  knowledge,  the  skill,  and 
the  training  which  is  at  present  given  nowhere  except  in  the  nursing 
schools.  It  is  essential  that  this  training  should  be  broad,  sound,  and 
thorough.  The  school  nurse  should  be  a  graduate  of  a  recognized 
general  training  school,  which  includes  special  work  with  children,  a 
good  experience  in  eye,  ear,  nose,  and  throat  work,  and  in  infectious 
and  skin  diseases.  She  should  also  have  a  thorough  training  in  every- 
thing that  relates  to  nutrition  and  general  hygiene. 

1  British  Journal  of  Nursing  (November  20,  1909). 


EDUCATIONAL  VALUE  OF  THE  NURSE  59 

There  can  be  no  question  about  the  high  personal  qualifications 
which  she  should  bring  to  her  work.  Such  a  vocation  demands  edu- 
cated women,  women  who  not  only  know  how  to  do  things  but  why 
they  do  them;  women  of  broad  sympathies  and  social  understanding 
as  well  as  practical  skill.  This  enlarging  field  of  nursing  activities 
makes  a  new  and  direct  call  on  the  hospital  training  schools  to  uphold 
high  standards  of  entrance  requirements  and  to  furnish  a  type  of  pro- 
fessional training  which  will  fit  the  student  not  only  for  private  and 
hospital  service,  but  for  the  social  and  educational  field  as  well. 

But  while  the  nursing  school  is  responsible  for  her  strictly  profes- 
sional education,  much  of  the  training  of  the  school  nurse  must  inevi- 
tably come  after  graduation.  If  she  is  to  be  an  expert  in  her  field,  she 
must  specialize  on  the  subject  of  children,  on  their  physical  and  mental 
constitution,  on  child  hygiene  and  child  psychology,  on  children's 
diseases,  the  history  of  infant  mortality,  the  social  movements  which 
involve  child  welfare,  etc.  She  should  also  be  in  touch  with  the  edu- 
cational problem,  so  that  she  can  co-operate  sympathetically  with  the 
work  and  the  ideals  of  the  school.  From  the  standpoint  of  sanitation 
and  public  health,  she  should  know  something  of  the  housing  problem, 
of  municipal  as  well  as  domestic  sanitation,  and  of  such  laws  and 
local  regulations  relating  to  them  as  will  enable  her  to  lay  hold  promptly 
on  all  the  agencies  of  relief. 

Sufficient  mention  has  been  made  of  the  social  functions  of  the  school 
nurse  and  of  the  many  ways  in  which  she  can  be  of  service  in  the  home 
and  in  the  community.  To  do  this  effectively  she  must  know  the 
social  agencies  at  work  in  her  city,  what  they  stand  for,  and  how  she 
can  co-operate  with  them.  She  should  also  be  in  touch  with  the  broader 
social  and  industrial  movements,  and  should  have,  if  possible,  some 
fundamental  knowledge  of  sociological  and  economic  principles.  In 
addition,  she  must  know  how  to  make  her  knowledge  available  to 
others.  Her  teaching  must  be  simple,  direct,  concrete,  and  forceful, 
if  it  is  to  reach  the  children  and  the  people  with  whom  she  deals.  This 
requires  some  knowledge  of  the  teaching  art. 

It  might  readily  be  urged  that  such  a  preparation  as  is  here  outlined 
would  take  years  to  acquire.  Eventually  some  special  training  will 
probably  be  required  by  those  employing  school  nurses.  In  the  mean- 
time the  wide-awake  nurses  are  doing  what  they  can  through  reading 
and  lectures  and  special  courses,  such  as  are  given  by  the  schools  of 


60  THE  NINTH  YEARBOOK 

civics  and  philanthropy,  the  better  to  fit  themselves  for  their  work. 
The  practical  experience  gained  in  district  nursing  cannot  be  over- 
estimated and,  as  has  been  pointed  out,  the  administration  of  school 
nursing  under  some  such  nursing  organization  would  tend  to  secure  a 
type  of  woman  better  trained  and  usually  more  devoted  to  social  serv- 
ice. Much  can  be  done  undoubtedly  through  conferences  of  school 
physicians  and  school  nurses,  and  general  meetings  with  teachers  and 
supervisors  in  physical  education,  domestic  science,  etc.  Discussion 
on  the  main  phases  of  this  work  must  find  a  place  in  educational,  medi- 
cal, and  nursing  conferences,  and  will  inevitably  bring  about  a  clearer 
understanding  and  more  active  co-operation  between  the  rank  and 
file  of  these  professions. 

The  great  demand,  both  on  the  part  of  the  public  and  of  nurses 
themselves  for  fuller  preparation  in  all  these  branches  of  nursing,  has 
been  felt  for  some  time.  The  need  now  is  for  an  institution  or  organi- 
zation that  will  give  the  preparation  required.  The  various  teachers' 
colleges,  in  association  with  hospitals  and  hospital-training  schools  for 
nurses,  are  the  means  at  hand.  The  one  significant  attempt  to  meet 
this  problem  is  that  undertaken  by  Teachers  College  at  Columbia 
University.  Through  the  generosity  of  Mrs.  Helen  Hartly  Jenkins 
this  institution  presents  a  one-year  course  under  the  control  of  the 
Department  of  Nursing  and  Health.  It  provides  an  experiment  and 
experience  upon  which  further  organization  of  training  schools  for 
school  nurses  may  well  be  based.  Its  distinct  aim  is  to  prepare 
"teacher  nurses"  for  district  nursing,  school  nursing,  board  of  health 
work,  etc.  Its  scope  is  much  as  outlined  above,  combining  the  social, 
economic,  educational,  sanitary,  and  nursing  phases  of  the  work.  A 
high-school  certificate,  or  its  equivalent,  and  a  diploma  from  a  recog- 
nized training  school  for  nurses  are  required  for  entrance.  Through 
affiliation  with  the  New  York  School  of  Philanthropy  and  the  Henry 
Street  Nurses'  Settlement,  the  students  have  unusual  opportunities 
for  combining  theoretical  and  practical  work  in  a  very  broad  field. 
They  will  also  have  the  advantage  of  observing  closely  the  methods 
employed  in  the  school-nursing  and  public-health  work  of  New  York 
City.  A  group  of  students  is  already  at  work  specializing  in  vari- 
ous fields.  It  is  hoped  that  this  type  of  course  will  prove  serviceable 
in  helping  to  solve  the  problem  of  the  special  preparation  of  the  school 
nurse. 


THE   PROFESSIONAL  TRAINING  OF   CHILDREN'S   NURSES 


MARY  L.  READ 


We  are  familiar  with  the  redundant  statements  and  appeals  of 
Pestalozzi,  Froebel,  and  Spencer  regarding  the  education  of  parents 
in  the  care  and  training  of  children,  and  the  oft-quoted  comments  of 
English  and  American  pediatricians  of  high  authority  on  the  ignorance 
of  mothers  as  among  the  chief  causes  of  infant  mortality.  On  the  pro- 
grams of  such  conferences  as  the  International  Mothers'  Congress  and 
the  International  Congress  for  Home  Education  there  frequently  appear 
addresses  and  discussions  on  such  topics  as  "The  Training  of  Nursery 
Maids,"  "A  National  School  for  Women,"  "  Supplementary  Education 
for  Girls  to  Fit  Them  as  Wives  and  Mothers."  Yet  it  is  perfectly  patent 
that  such  education,  briefly  and  practically  presented,  in  the  funda- 
mentals of  child  care  and  training  is  rarely  provided. 

The  phase  of  this  problem  with  which  the  present  report  is  con- 
cerned is  the  professional  training  of  women  for  paid  service  as  intelli- 
gent and  trained  care-takers  of  little  children,  either  in  private  homes  or 
in  institutions.  It  presents  the  results  of  a  superficial  survey  of  the 
present  situation,  including  the  demand  for  such  a  service;  its  oppor- 
tunities and  recompense;  the  provisions  for  training;  the  meeting  of 
practical  details  of  curriculum,  practice,  length  of  training,  social  rela- 
tions of  employer  and  employee;  and  suggestions  for  future  develop- 
ments. 

In  European  countries. — Among  the  first  pioneers  in  providing  prac- 
tical, comprehensive  training  in  the  physical  care  and  early  develop- 
ment of  infants  and  little  children  is  the  Pestalozzi-Froebel  Haus  in 
Berlin,  where  since  1874,  under  the  guidance  of  Froebel's  gifted  niece, 
Henrietta  Schrader-Breymann,  a  "mother  school"  and  kindergarten 
of  truly  Froebelian  simplicity  has  been  maintained.  A  direct  offshoot 
of  this  is  the  Sesame  House  in  London. 

About  1902  at  Ghent,  Belgium,  a  School  for  Mothers  was  started 
under  the  enthusiastic  direction  of  Dr.  Miele,  in  connection  with  the 
Bureau  de  Bienfaisance.  This  is  part  of  the  comprehensive  system  of 
infant  hospitals,  creches,  milk  depots,  and  dispensaries.     It  includes 

61 


62  THE  NINTH  YEARBOOK 

health  talks  to  mothers  (such  as  are  now  given  at  many  of  our  own  milk 
stations  and  infants'  clinics  in  the  large  cities),  and  training  courses  for 
girls  as  infants'  nurses,  with  practice  in  the  creches. 

In  Paris  the  Ecole  d'hygiene  d'education  familiale  et  sociale  d'en- 
seignement  menager,  which  was  founded  by  Mme  Augusta  Moll- Weiss 
at  Bordeaux  in  1897,  removing  to  Paris  in  1904,  provides  a  most  com- 
prehensive course.  One  section  is  for  professors  and  women  of  the 
higher  classes;  a  second  section  for  women  intending  to  enter  household 
service  as  nurses,  cooks,  etc. ;  a  third  section  for  women  of  the  working 
classes,  and  a  fourth  for  instruction  in  domestic  economy  and  home 
management. 

England  appears  to  have  developed  more  centers  for  the  training 
of  women  as  professional  children's  nurses  than  has  any  other  country. 

The  list  includes  Norland  Institute,  the  Liverpool  Ladies'  Sanitary 
Association  at  Liverpool,  the  Princess  Christian  Institute  at  Man- 
chester, the  Cheltenham  Guild  of  the  Dames  of  the  Household,  Sesame 
House,  St.  Christopher's  at  Tunbridge  Wells,  and  St.  Mary's  Nursery 
College,  London. 

The  reports  and  prospectuses  of  these  institutions  uniformly  state 
that  the  demand  for  their  graduates  far  exceeds  the  supply.  The 
salary  ranges  from  £24  per  year  for  recent  graduates  to  £50  for  the 
more  experienced.  Most  of  the  students  are  in  residence.  The  train- 
ing school  is  also  usually  a  resident  nursery  where  children  from  infancy 
to  six  months  are  received  and  their  care  is  paid  for  by  parents  or 
guardians.  Every  effort  is  made  to  maintain  a  home  atmosphere.  In 
general,  the  course  includes  both  theory  and  practice  in  hygiene,  nursery 
cooking  and  laundry,  home  nursing,  children's  sewing,  nursery  man- 
agement, kindergarten  principles  and  practice.  The  length  of  the 
course  varies  from  three  months  to  one  year.  There  is  no  salary  dur- 
ing such  training,  but  a  fee  is  charged  to  cover  tuition  and  living,  aver- 
aging from  £3!  to  about  £6  per  month,  according  to  the  particular 
school.  "Lady  nurses  for  children,"  "children's  nurses,"  "nursery 
nurses,"  "nursery  governesses"  are  different  terms  there  used  for  the 
same  profession.  All  of  these  schools  recognize  both  the  physical  and 
the  spiritual  nature  of  the  child,  and  the  need  of  training  for  the  care 
of  the  child's  physical,  mental,  and  moral  development. 

In  the  United  States. — The  training  in  this  country  has  been  chiefly 
for  "infants'  nurses,"  and  "nursery  maids,"  and  the  training  has  been 


TRAINING  OF  CHILDREN'S  NURSES  63 

done  almost  wholly  by  babies'  hospitals.  The  Babies'  Hospital  of  New 
York  City  has  maintained  such  a  course  for  about  twenty  years.  The 
course  includes  six  months  in  the  hospital,  with  instruction  in  infant 
hygiene,  care  and  feeding,  the  rudiments  of  kindergarten  work,  and 
ward  duty  in  the  care  of  sick  and  convalescent  children;  two  months 
are  then  spent  on  probation  in  private  families  before  a  certificate  is 
granted.  Nurses  receive  $7  a  month  during  training,  and  $25  per 
month  after  graduation  during  the  first  year,  usually  rising  to  $30  per 
month  thereafter.  About  thirty-five  such  nurses  are  trained  annually, 
and  the  demand  is  often  for  one  thousand  in  the  same  period.  The 
requirements  for  admission  are  good  health,  good  references,  and  ability 
to  read.  Married  women  and  widows  are  not  received.  Most  of  the 
girls  are  from  twenty  to  twenty-five  years  of  age.  The  applications  for 
admission  are  so  numerous  that  girls  frequently  have  to  wait  six  months 
after  acceptance  before  they  can  enter.  These  girls  seldom  have  more 
than  a  common-school  education.  In  the  families  of  employers  they 
are  ranked  as  domestic  servants,  called  by  their  first  names,  and  have 
their  meals  in  the  kitchen  with  the  other  servants;  they  usually  sleep 
either  in  the  children's  or  the  cook's  room.  Dr.  Holt  has  expressed  the 
opinion  that  young  women  of  better  education  and  personality  will  not 
enter  training  courses  for  nursery  maids,  because  of  this  social  relation 
to  the  family. 

Similar  training  schools  are  reported  to  be  conducted  at  the  follow- 
ing institutions:  St.  Christopher's  Hospital,  Brooklyn;  Nursery  and 
Child's  Hospital,  New  York  City;  The  Babies'  Hospital,  Newark,  N.J.; 
St.  Margaret's  Home,  Albany;  Infants'  Hospital,  Boston;  The  Pitts- 
burgh Home  for  Babies,  Pittsburgh,  Pa. 

A  course  for  nursery  maids  that  was  started  in  connection  with  the 
kindergarten  training  school  at  Pratt  Institute  some  years  ago  was 
abandoned  because  the  young  women  who  entered,  if  they  were  of 
desirable  intelligence  and  personality,  usually  concluded  by  taking  the 
entire  kindergartner's  course. 

A  course  for  "kindergarten  nurses"  was  started  by  the  Y.W.C.A. 
of  Harlem,  New  York  City,  in  1906,  but  was  later  abandoned — for 
what  reason  it  has  been  impossible  to  learn. 

An  attempt  was  made  some  years  ago  to  train  nursery  maids  in 
connection  with  the  day  nursery  of  Neighborhood  House,  Buffalo,  but 
this  also  was  abandoned  for  some  unknown  reason. 


64  THE  NINTH  YEARBOOK 

The  writer  has  been  unable  to  learn  of  any  training  course  in  this 
country  similar  to  that  offered  by  the  English  schools. 

REPORT  OF  A  PRELIMINARY  STUDY  ON  THE  NURSEMAID  PROBLEM 
CONDUCTED  IN  NEW  YORK  CITY,  1910 

The  study  took  up  the  problem  of  the  nursemaid  from  the  stand- 
point of:  (1)  the  employer;  (2)  the  employee;  (3)  the  employment 
agency;  (4)  the  nursemaid  training  school;  (5)  the  observer  of  nurse- 
maids in  parks  and  boulevards.  Questionnaire  blanks  were  arranged 
for  employer,  employee,  and  observer.  Interviews  were  held  with 
managers  of  employment  agencies,  directors  of  training  courses,  appli- 
cants for  nursemaid  positions.  Advertisements  were  inserted  in  the 
Sunday  papers  both  for  employment  and  for  nursemaids;  postcards 
were  sent  to  persons  advertising  for  nursemaid  positions;  advertise- 
ments for  nursemaid  and  for  mother's  helper  were  inserted  in  the  Out- 
look. The  returns  from  these  questionnaires,  interviews,  and  adver- 
tisements are  too  few  to  draw  final  conclusions,  but  they  at  least  give 
an  insight  into  the  situation. 

Only  twelve  replies  were  received  from  employers.  Seven  of  these 
found  no  difficulty  in  securing  the  kind  of  nursemaid  they  found  sat- 
isfactory; five  others  did.  Only  one  employer  paid  less  than  $20 
monthly,  some  as  high  as  $40.  With  one  exception,  the  nursemaid 
was  treated  as  a  servant,  was  called  by  her  first  name,  had  her  meals 
in  the  kitchen  with  the  other  servants,  usually  was  on  duty  from  7  a.m. 
to  7  p.m.  with  a  half-day  off  on  alternate  Sundays  and  Thursdays. 
The  qualifications  specified  as  necessary  (given  in  the  order  of  their 
frequency  in  replies)  were  cleanliness,  neatness,  honesty,  politeness, 
faithfulness  in  duties,  fondness  for  children. 

The  applicants  interviewed  at  employment  agencies  were  all  girls 
of  very  limited  intelligence  and  training,  and  at  several  agencies  the 
investigator  waited  all  the  morning  without  a  single  applicant  for  such 
a  position  appearing.  The  girls  interviewed  wanted  $18  to  $30  monthly, 
and  were  willing  to  assist  in  household  work,  but  objected  to  wearing 
a  uniform.  Some  of  the  employment  agencies  when  questioned  directly 
said  they  had  difficulty  in  finding  suitable  nursemaids;  others  reported 
no  difficulty  in  supplying  the  demand,  but  stated  that  the  training  con- 
sisted only  of  experience  in  previous  households.  The  employment  de- 
partment of  the  Charity  Organization  Society  reported  a  great  demand 


TRAINING  OF  CHILDREN'S  NURSES  65 

for  young  girls  to  "mind  the  baby,"  at  $12  to  $15  a  month.  The 
employment  department  of  the  Young  Women's  Christian  Association 
reported  that  they  did  not  register  nursemaids  "nor  other  domestic 
servants,"  but  that  they  had  calls  for  nursery  governesses  and  for 
mothers'  helpers.  The  "nursery  governess"  is  understood  by  them  to 
be  a  young  woman  of  superior  breeding  whose  influence  on  the  chil- 
dren is  refining;  she  sometimes  has  also  the  physical  care  of  the  children, 
but  in  some  families  this  is  done  by  the  mother  or  by  a  nursemaid.  The 
greatest  demand  is  for  the  English  trained  nursery  governesses,  and 
after  that  for  Hanoverian  or  French.  The  "mother's  helper"  they 
defined  as  intermediate  in  social  rank  and  responsibilities  between  the 
nursemaid  and  the  nursery  governess. 

Postcards  were  sent  for  about  two  weeks  to  all  applicants  for  nurse- 
maid positions  advertising  in  the  chief  city  dailies,  but  only  one  in  five 
came  for  an  interview,  and  these  were  chiefly  the  uneducated,  untrained 
type.  The  responses  to  advertisements  inserted  in  the  daily  papers 
were  equally  unsatisfactory.  Two  advertisements  were  inserted  in  the 
same  issue  of  the  Outlook,  one  for  a  nursemaid,  the  other  for  a  mother's 
helper.  One  reply  was  received  for  the  former,  and  twenty  for  the 
latter.  These  twenty  deserve  analysis.  One  was  English,  the  others 
American,  chiefly  from  the  eastern  states.  Three  were  trained  hospital 
nurses,  four  were  college  women,  and  seven  more  had  a  high-school 
education,  one  was  a  teacher,  four  were  nursery  governesses,  two  were 
nurses,  and  twelve  others  reported  experience  in  the  care  of  children. 
Many  specified  willingness  to  help  with  sewing  or  light  household  duties. 
The  wages  requested  were  from  $20  to  $30  monthly. 

Only  twelve  questionnaire  blanks  were  returned  from  observations 
of  nurses;  six  of  these  reported  no  adverse  criticisms,  one  reported 
unseemly  conduct,  three  ill-treatment,  and  two  neglect.  The  blank  was 
so  prepared  that  any  adverse  criticism  had  to  be  based  upon  an  actual 
concrete  case,  with  particulars,  on  the  date  the  observation  was  made. 

The  directors  of  two  of  the  training  schools  for  nursery  maids  (con- 
nected with  hospitals)  were  interviewed.  They  both  stated  that  the 
demand  for  their  graduates  exceeded  the  supply,  and  that  the  applica- 
tions for  admission  were  far  in  excess  of  their  facilities  for  training. 
Their  students  are  chiefly  young  girls  of  only  common-school  education. 
One  of  the  physicians  longest  connected  with  such  training  expresses  the 
opinion  that  it  can  be  conducted  equally  well  in  co-operation  with  day 


66  THE  NINTH  YEARBOOK 

nurseries  and  kindergartens;  but  that  because  of  the  social  status  of 
the  nursemaid  in  the  family  it  would  be  difficult  to  find  young  women 
of  the  desired  education  and  personality  to  take  the  training. 

A  study  of  some  fifty  day  nurseries  in  one  of  our  largest  cities  reveals 
that  much  less  than  half  of  the  care-takers,  infants'  nurses,  or  matrons 
are  trained  for  the  physical  or  mental  care  of  the  child.  Inspection  of 
the  curriculum  of  kindergarten  training  schools  indicates  that  few  of 
them  give  instruction  in  the  physical  nature  and  care  of  the  child.  A 
report  based  on  a  study  of  forty  normal  schools,  presented  at  the  con- 
ference of  the  Association  for  the  Study  and  Prevention  of  Infant 
Mortality  at  Baltimore  last  November,  states  that  hygiene  is  very 
impractically  and  inadequately  taught  in  most  of  these  schools. 

The  questions  which  this  study  raises  are  these: 

i.  Should  not  all  training  schools  for  teachers  include  due  recog- 
nition of  the  child's  physical  life  and  its  development  and  care  ? 

2.  Is  it  not  possible  by  co-operation  between  normal  schools  or 
kindergartens  and  day  nurseries  or  foundling  homes  to  give  such  a 
practical  training,  and  that  in  the  course  of  a  few  months  ? 

3.  What  agencies  should  take  the  initiative  in  this  country  in  pro- 
viding such  a  course  for  mother's  helpers  and  nursery  governesses  as 
is  now  provided  by  the  training  schools  for  children's  nurses  in  England  ? 

4.  Is  it  not  possible  by  such  a  course  to  train  great  numbers  of  young 
women  who  would  live  at  home  and  give  only  day  service  to  one  or 
more  families,  thus  helping  to  solve  both  the  question  of  social  status 
and  of  nurse  hire  for  the  family  of  moderate  means  ? 

Following  is  a  more  detailed  description  of  these  English  schools 
for  which  data  is  at  hand. 

At  Norland  Institute  the  training  lasts  for  one  year,  the  fees  amount- 
ing to  £74  85.,  which  includes  living,  laundry,  tuition,  and  the  first  uni- 
form. The  first  twelve  weeks  are  spent  at  Norland  Institute  (which  is 
also  a  resident  nursery).  Here  thorough  instruction  is  given  in  cook- 
ery, laundry  work,  housewifery,  hygiene,  nursery  management,  the 
making  of  simple  garments.  The  student  then  serves  a  term  in  one  of 
the  children's  hospitals,  after  which  she  returns  to  the  Institute  and 
receives  a  course  of  instruction  in  the  Froebelian  methods  of  teaching 
and  becomes  first  an  under  nurse  and  afterwards  charge  nurse  in  the 
Norland  Nurseries.  This  Institute  was  started  in  1894  and  about  one 
thousand  nurses  have  received  the  training. 


TILilXIXG  OF  CHILDREX'S  XURSES  67 

The  Liverpool  Ladies'  Sanitary  Association  began  with  non-resi- 
dential training,  but  in  1908  opened  its  Residential  Training  Home  for 
Lady  Nurses  for  Children.  Educated  ladies  receive  here  a  six  months' 
training  as  children's  nurses.     Quoting  from  the  announcement: 

The  demand  for  fully  trained,  competent,  well-educated  women  as  Lady- 
Nurses  for  children  is  at  present  much  in  excess  of  the  supply,  and  it  is  hoped 
that  in  the  future  the  profession  will  be  adopted  by  an  increasingly  large  num- 
ber of  those  who  have  a  real  love  for  children. 

If,  as  we  all  must  admit,  true  education  begins  in  the  nursery,  the  value 
of  the  well-trained  nurse  cannot  be  over  estimated.  The  L.L.S.A.  have  recog- 
nized this  in  drawing  up  their  syllabus,  and  the  training  given  is  calculated 
to  impress  upon  the  nurse  that  the  mental,  moral,  and  spiritual  characteristics 
of  the  child  must  all  receive  their  due  share  of  consideration,  and  that  the 
nurture  of  the  young  includes  alike  the  care  of  the  mind  and  the  body. 

Special  lecture  courses  by  selected  instructors  are  given  on  nursery  man- 
agement, hygiene,  feeding  of  infants,  and  kindergarten;  and  special  instruction 
is  given  in  needlework,  elementary  cooking,  and  laundry  work.  Practical 
experience  in  the  care  of  infants  and  young  children  is  given  in  the  L.L.S.A 
Day  Nursery. 

The  tuition  fee  for  non-resident  students  is  £20;  for  residents  £30, 
including  board  but  not  laundry.  Candidates  come  for  a  month's 
probation;  if  not  considered  suitable  for  the  training,  they  may  be 
asked  to  withdraw  without  explanation.  Those  completing  the  course 
are  expected  to  wear  the  uniform — a  dark  green  bonnet  and  coat. 
On  the  completion  of  two  years'  satisfactory  service,  a  second  certifi- 
cate and  the  badge  of  the  Association  are  given. 

The  Princess  Christian  College  at  Manchester  was  started  in  1904 
"for  training  ladies  as  children's  nurses,"  under  the  management  of  the 
Gentlewomen's  Employment  Association  (and  later  incorporated  as  a 
separate  company)  under  the  patronage  of  Princess  Christian. 

The  college  was  established  "to  meet  the  increasing  demand  for 
ladies  as  children's  nurses,  and  to  provide  the  necessary  training  for  a 
career  which  is  so  eminently  suited  for  educated  women  who  have  a 
natural  sympathy  with  young  children." 

A  resident  nursery  is  maintained  for  children  of  the  better  class  only, 
the  minimum  period  for  their  residence  being  three  months,  and  the 
maximum  age  six  years.  Here,  as  in  the  other  similar  training  schools, 
the  nursery  department  is  the  vital  feature  of  the  training.     The  sub- 


68  THE  NINTH  YEARBOOK 

jects  taught  include  general  rules  of  health,  first  aid  and  home  nursing, 
infant  feeding,  nursery  management,  domestic  work,  nursery  laundry 
work  and  cookery,  needlework,  kindergarten  games,  drilling,  etc. 

Candidates  are  not  admitted  under  twenty  years  of  age,  and  must  be 
resident  in  the  college.  Students  are  on  probation  the  first  fortnight, 
but  may  be  required  to  withdraw  at  any  time  if  found  unsuitable  for 
the  work.  The  work  is  in  charge  of  a  principal,  and  under  her  are  the 
two  resident  teachers — one  for  domestic  science,  laundry,  cookery, 
and  the  other  for  needlework  and  housewifery — a  hospital  trained 
nurse  in  charge  of  the  nurseries,  and  three  outside  lecturers — one  for 
kindergarten,  one  for  physiology,  first  aid,  etc.,  and  one  for  child-study. 

In  the  Fourth  Annual  Report  (1908)  of  the  college  are  printed  the 
rules  for  employers  and  for  employees,  covering  such  items  as  salaries, 
duties,  holidays,  testimonials,  social  relations,  etc.  Nurses  are  entitled 
to  four  weeks'  annual  holiday;  are  not  to  scrub  grates  or  floors,  nor 
carry  coal,  though  they  will  dust  rooms  and  make  beds;  are  not  to  take 
their  meals  with  the  house  servants  (nursery  maid  excepted),  nor  in 

their  bedrooms;  are  to  be  addressed  as  Miss ;  are  obliged  to  wear 

the  college  uniform  when  on  duty.  A  month's  notice  is  required  before 
the  termination  of  an  engagement.  During  the  first  two  years  after 
graduation  the  college  finds  the  posts  for  the  nurses,  and  collects  their 
salary  for  them  in  quarterly  instalments ;  thereafter  they  find  their  own 
posts  and  arrange  and  collect  their  own  salaries. 

The  training  consists  of  two  terms  of  fifteen  weeks  each,  the  fee 
for  tuition,  living,  and  laundry  being  sixty  guineas. 

The  Sesame  House,  43A  Acacia  Road,  London,  a  training  college 
planned  on  the  lines  of  the  Pestalozzi-Froebel  Haus,  Berlin,  was  opened 
in  1899  under  the  auspices  of  the  Sesame  Club.  As  stated  in  the  first 
yearbook,  the  general  purpose  is  to  fit  girls  and  women  more  fully  for 
the  woman's  life,  and  the  second  purpose  is  to  fit  girls  who  need  to  earn 
their  livelihood,  as  certified  lady-nurses  to  children,  as  kindergarten 
teachers,  as  nursery  governesses,  for  whom  there  is  a  great  demand,  and 
for  settlement  work.     Quoting  from  this  same  yearbook: 

Many  girls,  unfitted  by  previous  education  to  compete  in  the  examinations 
of  the  day,  yet  in  possession  of  gifts  to  be  in  no  wise  under-valued,  are  thus 
enabled  to  prepare  themselves  for  a  sheltered  and  refined  life,  which  offers 
far  larger  opportunities  of  out-giving  and  of  general  self -development  than  the 
mechanical  life  of  a  bookkeeper  and  shorthand  writer. 


TRAINING  OF  CHILDREN'S  NURSES  69 

The  work,  both  theoretical  and  practical,  is  so  arranged  as  to  center 
around  the  education  and  nurture  of  children  and  the  internal  manage- 
ment of  a  household  in  all  its  branches.  Both  resident  and  non-resi- 
dent students  are  received.  There  are  three  terms  of  thirteen  weeks 
each,  the  work  of  each  term  being  guided  by  the  season.  Students  may- 
enter  at  the  beginning  of  any  term.  A  certificate  is  granted  to  students 
satisfactorily  finishing  the  year's  training. 

The  mornings  are  given  to  practical  work  in  the  house,  kitchen,  or 
garden,  or  with  the  children.  This  includes  a  regular  course  in  cookery, 
house  management,  cleaning,  nursery  laundry,  needlework  (children's 
garments  and  mending),  vegetable  and  flower  gardening.  In  the  after- 
noons, classes  are  given  in  nature-studies,  singing,  geometry,  art,  domes- 
tic hygiene,  and  house  sanitation,  Froebel  occupations,  educational 
history,  principles,  and  methods. 

The  children  of  the  free  kindergarten  and  the  Sesame  Nursery  House 
furnish  the  practice.  A  fourth  term  of  three  months,  in  the  Sesame 
Nursery  House,  in  the  care  and  feeding  of  infants  is  required  of  students 
training  as  lady  nurses. 

The  tuition  fee  is  £10  per  term;  board  and  residence  is  £14  per 
term,  with  accommodations  for  twenty-eight. 

St.  Mary's  Nursery  College,  in  London,  was  opened  in  1908,  "to 
provide  for  the  training  of  Catholic  gentlewomen  as  nursery  nurses." 
The  college  "provides  an  inexpensive  training  for  educated  women  who 
have  natural  sympathy  with  little  children."     The  training  includes: 

I.  A  practical  course: 

The  dailv  care  and  feeding  of  resident  infants  and  children,  from  a  fort- 
night to  five  years  old 

Tli"  duties  and  management  of  a  nursery  (all  the  work  being  done  by  the 
students) 

Nursery  cooking 

Nursery  laundry 

Needlework    (cutting-out   and   making   of   children's   clothes,    knitting, 
mending) 
II.  A  course  of  instruction  given  by  qualified  teachers  on  the  following  subjects: 

The  religious  teaching  of  young  children 

Nursery  hygiene 

Child  physiology 

First  aid 

"Kindergarten  occupations,  games,  and  songs 


70  THE  NINTH  YEARBOOK 

The  principal,  Mrs.  Bernard  Mole  (Clapham  Maternity  Hospital 
certificate),  is  assisted  by  a  trained  children's  nurse,  domestic-economy 
and  kindergarten  (Froebel  Union)  teachers,  medical  and  other  lecturers. 
Quoting  from  the  announcement: 

If,  as  is  generally  admitted,  true  education  begins  in  the  nursery,  the  value 
of  a  well-trained  nurse  cannot  be  over-estimated.  The  training  will  also  be  of 
value  to  those  entering  upon  the  responsibilities  of  married  life  and  to  others 
who  may  not  intend  to  adopt  nursing  as  a  profession. 

Students  satisfactorily  completing  the  six  months'  course  are  granted  a 
certificate  and  are  entitled  to  wear  the  uniform  of  the  College.  The  fee  for 
six  months'  training,  board,  and  residence  is  £36. 

At  the  Cheltenham  Creche  a  three-months'  course  is  given,  to  either 
resident  or  non-resident  students,  there  being  accommodations,  however, 
for  only  four  residents.  The  fee  for  three  months'  residence  and  train- 
ing is  £10. 

The  National  Froebel  Union  has  recently  created  a  new  section 
designated  "The  Child  Attendant  Association"  which  grants  a  cer- 
tificate of  practical  fitness  for  the  duties  of  such  attendants,  after  train- 
ing under  conditions  which  meet  with  their  approval  and  which  are 
open  to  their  inspection.  Their  "provisional  scheme  for  training  child 
attendants  for  infants'  and  nursery  schools"  calls  for  a  six-months' 
training  with  daily  work  under  supervision  in  a  selected  school,  such 
work  including  reception  and  inspection  of  children  for  symptoms  of 
disease,  washing,  supervision  of  lavatories,  disinfection  of  garments 
when  needed,  first  aid,  organization  and  supervision  of  lunches.  It 
also  requires  three  twelve-hour  series  of  class  lectures  and  demonstra- 
tions on  (1)  elements  of  child  hygiene  and  care,  (2)  characteristics  of 
normal  and  abnormal  children,  (3)  personal  care,  first  aid.  The  train- 
ing is  estimated  to  cost  for  six  months  £4  45.  to  £6  6s. 

Two  London  kindergartens  are  now  giving  such  training. 

In  a  notable  address  before  the  Religious  Education  Association  in 
1907  on  the  "  Relation  of  the  Home  to  Moral  and  Religious  Education," 
Commissioner  Elmer  E.  Brown  urged  the  establishment  of  special 
training  courses  for  young  women  of  education  and  personality  to  care 
for  little  children  under  the  school  age;  and  the  consequent  develop- 
ment of  a  new  profession  for  women.  He  calls  attention  to  the  intimate 
relation  between  the  moral  education  of  little  children  and  their  physi- 
cal welfare,  especially  their  habits  of  eating,  sleeping,  and  related  activi- 


TRAINING  OF  CHILDREN'S  NURSES  71 

ties  which  involve  the  nervous  system.  He  points  out  the  great  range  of 
requirements  both  of  knowledge  and  judgment — nutrition,  the  preven- 
tion of  disease,  the  treatment  of  minor  ailments,  the  correction  of  faults 
of  temper  and  disposition,  the  first  steps  in  learning,  the  supervision  of 
games,  the  telling  of  stories,  the  first  hint  of  the  mysteries  of  religion. 

It  is  accordingly  desirable  [he  addsl  that  in  training  for  this  service  we 
should  break  away  from  the  narrower  traditions  of  the  kindergarten.  Many 
good  precedents  may  be  drawn  from  the  training  of  nurses  in  hospitals  and 
sanitariums,  but  even  such  precedents  must  be  followed  with  caution.  These 
things  seem  clear  to  this  extent,  at  least,  that  the  training  should  join  theory 
with  practice,  and  that  the  work  must  be  partly  pedagogical  and  partly  parallel 
to  that  of  the  ordinary  nurses'  training  school. 

He  suggests  that  the  theoretical  instruction  could  probably  best  be 
given  in  connection  with  a  college  or  university,  thus  the  more  readily 
attracting  young  women  of  the  desired  preliminary  training,  the  stu- 
dents having  access  to  a  babies'  hospital,  foundlings'  home,  day  nurs- 
ery, or  other  children's  institution. 


BIBLIOGRAPHY 

The  references  classified  below  under  several  headings  have  been 
selected  for  the  purpose  of  making  available  for  teachers  and  educational 
authorities  generally  literature  dealing  with  various  aspects  of  nursing 
as  related  to  education.  Regarding  the  general  subject  of  Medical 
Inspection  of  Schools  reference  is  made  to  the  Bibliography  in  Part  I 
of  the  Ninth  Yearbook  of  this  Society. 

GENERAL  WORKS  ON  SCHOOL  HYGIENE  AND  PUBLIC  HEALTH  WITH  REFERENCE 

TO   SCHOOL  NURSING 

Allen,  William  H.     Civics  and  Health. 

Cronin,  Dr.    Reports  upon  Medical  Inspection  in  the  City  of  New  York. 

Crowley,  Ralph  H.     The  Hygiene  of  School  Life. 

Fisher,  Professor  Irving.    Bulletin  jo,  Report  on  National  Vitality. 

Gulick  and  Ayres.    Medical  Inspection  of  Schools. 

Hayward,  John  A.,  M.D.,     " Co-operation  of  Doctor,  Teacher,  and  Nurse 

in  Medical  Inspection"  (Second  International  Congress  of  School  Hygiene). 
Hogarth,  A.  H.    Medical  Inspection  of  Schools. 
Newmayer,  S.  W.    A  Practical  System  of  Medical  Inspection  with  Trained 

Nurses. 
Osier,  Dr.    "  Medical  and  Hygienic  Inspection  in  Schools  "  (Second  International 

Congress  of  School  Hygiene) . 
Snedden  and  Allen.    School  Reports  and  School  Efficiency. 
Steven,  Edward  M.    Medical  Supervision  in  Schools  (iqio). 
Reports:   Board  of  Health — Los  Angeles,  San  Francisco,  Chicago,  Baltimore, 

Cambridge,  Detroit,  New  York,  etc. 
International  Congress  of  School  Hygiene,  London,  1907. 
National  Education  Association. 
Of  schools — Boston,  Brookline,  Cleveland,  Philadelphia,  Seattle,  etc. 

THE  HISTORY,   ORGANIZATION,   AND  ADMINISTRATION  OF    SCHOOL   NURSING 

Addams,  Jane.     "The  Visiting  Nurse  and  the  Public  Schools,"  American 

Journal  of  Nursing  (August,  1908). 
Ashe,  E.  H.     "A  Plea  for  School  Nurses  in  San  Francisco,"  Nurses'  Journal 

of  the  Pacific  Coast  (May,  1908). 
Baker,  S.  J.  (M.D.) .     "The  Trained  Nurse  in  the  Public  Schools  of  New  York,' ' 

Visiting  Nurses'  Quarterly  (April,  1910). 

72 


BIBLIOGRAPHY  73 

A.  M.  B.     "School  Nursing  or  the  Teacher  of  Practical  Hygiene,"  Visiting 

Nurses'  Quarterly  (Cleveland,  April,  1910). 
Darlington,  Dr.     Woman's  Municipal  League  Bulletin  (New  York,  January, 

1910). 
Dock,  L.  L.     "School  Nurse  Experiment  in  New  York,"  American  Journal  of 

Nursing  (November,  1902). 
Dorr,  Rita  Childe.     "A  Fighting  Chance  for  the  City  Child,"  Hampton's 

Magazine  (1909). 
Edwards,   A.   D.    (M.D.).       "School   Nurses'  Work  among   Children  and 

Parents,"  British  Journal  of  Nursing  (August  29,  1908). 
Ellicott,  Mrs.  William.     "The  Trained  Nurse  in  the  Public  Schools,"  Johns 

Hopkins  Alumnae  Magazine  (November,  1904). 
H.  M.  F.     "School  Nurses  in  London,"  The  Queen's  Nurses  (August,  1906). 
Forbes,  Dr.  Duncan.     "Work  of  the  School  Nurse  under  the  Medical  Officer 

of  Health,"  Report  of  the  Second  International  Congress  of  School  Hygiene. 
Hayward,  Dr.    Address  given  at  Jubilee  Congress  of  District  Nursing — Quoted 

in  Visiting  Nurses'  Quarterly  (Cleveland,  April,  1910). 
Heffern,  A.  I.     "The  School  Nurse  and  Her  Work,"  The  Craftsman  (Sep- 
tember, 1908). 
Hickey,  E.  M.     "School  Nursing,"  Nurses'  Journal  of  the  Pacific  Coast  (Octo- 
ber, 1908). 
Hughes,  Amy.     "School  Nurses,"  The  Queen's  Nurses  (April,  1905). 
Kavanaugh.     "  School  Nursing,"  Nurses'  Journal  of  the  Pacific  Coast  (January, 

1910). 
Kerr,  A.  W.     "School  Nursing  in  New  York  City,"  American  Journal  of 

Nursing  (November,  1909). 
McMurchy,  Helen  (M.D.).     "The  Visiting  Nurse  and  the  Children  Requiring 

Special  Attention,"  N.E.A.  Report,  1908. 
Morten,  Honnor.     "The  London  Public  School  Nurse,"  American  Journal 

of  Nursing  (January,  1901). 
.     "School  Nurses  in  England,"  Charities  and  the  Commons  (April  17, 

1906). 
.     "The  School  Nurse,"   Report  of  Third  International  Congress  of 


Nurses,  1901. 

Nutting,  M.  Adelaide.  "The  Nurse  in  the  Public  School,"  The  Education 
and  Professional  Position  of  Nurses  (U.S.  Bureau  of  Education). 

Pearse,  Helen  L.  "The  Place  of  the  School  Nurse,"  British  Journal  of  Nurs- 
ing (August  17,  1907). 

Rogers,  Lina  L.  "School  Nursing  in  New  York  City,"  American  Journal  of 
Nursing  (March,  1903). 

.     "Some  Phases  of  School  Nursing,"  American  Journal  of  Nursing 

(September,  1908). 


74  THE  NINTH  YEARBOOK 

Rogers,  Lina  L.     "  School  Nursing  in  Pueblo,"  Canadian  Nurse  (April,  1909). 

.     "What  the  Public  School  Nurse  Is  Doing,"  Visiting  Nurses'  Quarterly 

(Cleveland,  April,  1910). 
.     "Nurses  in  the  Public  Schools  of  New  York  City,"  Charities  and 


the  Commons  (April  7,  1906). 
Rose,   Frederick   (M.D.).     "The  Nurse  in  the  Open-Air   School,"   British 

Journal  of  Nursing  (November  20,  1909). 
Shaw,  F.  Madeline.     "The  Visiting  Nurse  and  Her  Work,"  Canadian  Nurse 

(January,  1909). 
Wald,  Lillian  D.     "Medical  Inspection  of  the  Public   School,"   American 

Academy  of  Political  and  Social  Science  (1905),  Vol.  XXV. 
.     "Educational  Value  and  Social  Significance  of  the  Trained  Nurse 

in  the  Tuberculosis  Campaign,"  Report  of  Sixth  International  Congress 

upon  Tuberculosis,  Vol.  III. 
Waters,  Yssabella.     Visiting  Nursing  in  the  United  States. 
Witmer,   Lightner    (M.D.).     "The   Hospital    School,"   Psychological   Clinic 

(October  15,  1907). 

EXPERIENCES  OF   SCHOOL  NURSES 

Harris,  Bertha.     "Side  Lights  on  School  Nursing,"  Nurses'  Journal  of  the 

Pacific  Coast  (February,  19 10). 
Kefauver,  C.  R.     "Obstacles  in  the  Path  of  the  School  Nurse,"  American 

Journal  of  Nursing  (August,  1909). 
Mack,  All.     "The  School  Nurse,"  British  Journal  of  Nursing  (July  28,  1906). 
S.  W.  N.     "Amusing  Experiences  of  a  School  Nurse,"  American  Journal  of 

Nursing  (February,  1908). 
"School  Nursing,"  The  Queen's  Nurses  (December,  1905). 
"Nursing  in  National  Schools  of  Ireland,"  ibid.  (December,  1909). 

SOME  REPORTS  AND  PERIODICALS  WHICH  SHOW  THE  VARIOUS  ASPECTS  OF 
NURSING  AS  RELATED   TO  EDUCATIONAL  AND   SOCIAL  WORK 

Periodicals: 

American  Journal  of  Nursing. 

British  Journal  of  Nursing. 

Canadian  Nurse. 

Nurses'  Journal  of  the  Pacific  Coast. 

Out-Door  Life. 

The  Queen's  Nitrses  (England). 

Survey. 

Tuberculosis  League  of  Pittsburgh. 

Visiting  Nurses'  Quarterly  (Cleveland). 


BIBLIOGRAPHY  75 

Reports  of: 

American  Society  of  Superintendents  of  Training  Schools,  1893  to  1910. 

Association  for  Improving  the  Condition  of  the  Poor  (New  York). 

Conferences  on  Infant  Mortality,  1909  and  1910. 

Charity  Organization  Societies. 

International  Congress  on  Tuberculosis,  1908,  Vol  III. 

International  Congress  of  Nurses,  1901  and  1909. 

Jubilee  Congress  of  District  Nursing  (Liverpool),  May,  1909. 

child  nurse:  training 

Abbott,  Ernest  Hamlin.     Training  of  Parents  (1908). 

Ausset,  E.  Elements  d'hygiene  infantile  a  Vusage  des  etablissements  oVeduca- 
tion  de  jeunes  filles.  (Lecons  faites  a  l'Ecole  normale  d'institutrices  de 
Douai  et  aux  grandes  eleves  des  ecoles  de  Saint-Pol-sur-Mer.)     Paris: 

C.  Delagrave,  1905.     i2mo,  viii+86  pp. 

Brown,  Elmer  Ellsworth.  "Training  for  Mother- Work,"  in  his  Government  by 
Influence  and  Other  Addresses,  pp.  167-84.  New  York,  London  [etc.]: 
Longmans,  Green  &  Co.,  1910.  Also  in  Proceedings  of  the  Religious  Edu- 
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Bunting,  Evelyn  M.,  and  others.  A  School  for  Mothers.  London:  H.  Mar- 
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Papers  by  Lady  Riicker,  member  of  Board  of  Studies,  Kimp  College 
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te  Haarlem;  Amalie  von  Schalscha-Ehrenfeld,  Berlin;  Pauline  Herber, 
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fesseur  d'Ecole  professionnelle  a  Gosselies;  Dr.  Oct.  Dauwe,  Antwerp; 
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institutrice  communale,  Brussels;  Helene  M.  Demetresco,  directress  of 
state  school  of  household  arts,  Bucharest;  Benjamin  R.  Andrews,  Colum- 
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76  THE  NINTH  YEARBOOK 

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